Viewpoint Volume 5 Issue 2 Summer Solstice 2019 by VerdenGroup

WELCOME VIEWPOINTISTHEVERDENGROUP'SQUARTERLY MAGAZINEPROVIDINGOURPERSPECTIVES ONTHEBUSINESSOFHEALTHCARE

ABOUTVIEWPOINT&theverden group

ViewPoint is a digital publication that looks at the business of healthcare from the perspective of The Verden Group's consulting professionals and other colleagues working in the field. Subscribe to ViewPoint to stay on top of all our news and views on the business of health care. Read past issues of the magazine and additional content at: ver den view poin t .com The Verden Group is an innovative consulting firm focused on educating and empowering medical practices to navigate through the increasingly complex business of healthcare. The Verden Group delivers expert consulting services and advice to individuals and groups of any size, from start-ups to super groups. From credentialing to contract negotiations and management, marketing to social management, PCMH transitions and strategic retreats ? we are your Partner In Practice. To learn more about our services, visit w w w.t h ever den gr ou p.com

www.verdenviewpoint.com

INTHISISSUE staffing&recruitment

payment model trends

shoul dyouusea 08 staffing: professional recruiter?

The prosand consof managing the recruitment processin-house vs. hiring a professional recruiter?

What isa PEO and what can it do to improve your practice'shuman resourcesmanagement?

under theradar: medicare&medicaid payment model trends

The potentially major impactsof Medicare & Medicaid payment changeson your practice.

is aprofessional empl oyer organizationright for your practice?

theimportanceof active l istening Active listening isa fundamental communication skill that leaderscan and should learn.

practicebil l ing: in-houseVS. outsource

spotl ight: aninterviewwith Dr. Liber The highsand lowsof transitioning from in-house to outsourced billing after 30 years.

Dr. Seth Kaplan shareshisexperienceson both sides of the in-house vs. outsourced billing discourse.

INTHISISSUE Bil l ing: in-houseor outsource?

social mediamanagement

social media: shoul dyouhirean expert?

Asyour primary outreach to patients, your online presence may need a professional touch.

Social media isan essential tool for promoting your practice. To get it done right, hire a pro!

isOUTSOURCingYOURONLINEPRESENCE thebest option?

ehr transition: taketwo catchingupwithdr. Rogu

pointsof view: recommendedreading A selection of curated newsworthy linksby the team at The Verden Group.

Dr. Rogu changed hismind about EHRsand his story may just change yourstoo.

To subscribe and read back issuesvisit:

www.verdenviewpoint.com

THISISSUE'SCONTRIBUTORS STAFF Publisher Susanne Madden Copy Editor & Layout Heidi Hallett Cover Design Scott Hodgson Web Master Scott Beyer

SUSANNEMADDEN, MBA, PCMHCCE FOUNDER&CEO THEVERDENGROUP

BrandonBetancourt,mba PracticeManagement consultant CONTRIBUTINGEDITOR HEIDIHALLETT contributor &creativeconsultant THEVERDENGROUP

Produced by The Verden Group, ViewPoint is available by free subscription and distributed seasonally. Print copies are available by request. Please contact us for pricing.

contact

Tiffany Lauria, Researcher, Project Coordinator THEVERDENGROup

NoreenQuadir, Social media&CommunicationsSpecial ist theverden group

guest contributorsthisissue

The Verden Group 48 Burd Street Suite 104 Nyack, NY 10960 877-884-7770 inquiry@theverdengroup.com www.VerdenViewPoint.com

dr. Dan Feiten, MD Remedy COnnect

Dr. SethKapl an, MD TLCPediatrics

DougGray,PhD ActionLearningAssociates

LETTERFROMTHEPUBLISHER

With the transition of the seasons into summer, our thoughts turn to longer, brighter days, outdoor activities, vacations. The warmth of the sun tugs at us to spend and enjoy more time with friends and family. . . However, when you own and run a medical practice, the demands on your time are many. It can be challenging to find the balance between doing it all yourself or even, delegating tasks to colleagues and employees. As a result, opportunities to take time off are few and far between. What if there was an alternative to getting things done right and on time? In this issue, we tackle the benefits of outsourcing. We look at several tasks and responsibilities that often benefit from outsourcing. We explore when hiring an expert to handle your practice billing might be the right solution versus having a skilled in-house employee. Social media management, recruitment, and human resources are also areas that we look into in this issue, offering you different points of view and expert advice on how to decide what is best for your practice. We?ve got a great list of guests and contributors to this issue. After all, we couldn?t do an issue on outsourcing without utilizing some of our best partners and colleagues. Leadership consultant and executive coach, Doug Gray, PhD, offers us excellent advice and tips on how to be an active listener; Dr. George Rogu talks with Brandon Betancourt to unpack the ups and downs of EHR transitions; and Dr. Seth Kaplan relays his experiences with in-house and outsourced billing (hint: it all comes down to having the 'right' people). When it comes to outsourcing, there is no ?one size fits all? solution ? you have to take the time to research your options and be willing to take some risks before you land on the best solution for your practice. However, knowing when to bring in outside help ? or expert help ? can be a lifesaver for your practice. Perhaps, and more importantly, outsourcing may be the solution that gives you the peace of mind that you need to actually step away from your practice from time to time, and give in to the summer tug while the sun still shines . . . Wishing you (occassional) lazy days ahead!

Susannemadden 7

Staffing: Shoul dyouuse aprofessional recruiter? Tiffany Lauria, Researcher & Project Coordinator

Healthcare support occupations, practitioners and technical occupations are among the fastest growing occupational groups in the United States, being projected to contribute one-fifth of all new jobs by 2026. While it is unlikely that most practices will grow as fast as pr oject ed industry trends, it is likely that your practice will continue to on-board clinical and support staff as demand for staffing increases and you deal with potential employee turnover. Should a medical practice manage the recruitment and interviewing process in-house or hire a professional recruiter?

Th e Case f or t h e Exper t s When hiring professional help, cost is always an issue that must be considered. Indeed, partnering with a recruiting professional can be costly. However, it is important to not focus exclusively on the expense. Rather, take into consideration both the cost and the value a professional recruiter provides.

recruitment Tim e The recruiting process can be extensive and time consuming. From drafting and posting job advertisements, reviewing candidate resumes and applications, to initial interviews, and grading candidates, these tasks can consume in-house hours that pull your current staff away from revenue producing activities. Once potential candidates are selected, additional work is often required for setting up secondary interviews, reference verifications, follow up email conversations, and phone calls. All of these tasks hinder your current employee?s ability to perform their day-to-day responsibilities, redirecting staff from being more productive.

When recruiting for new staff, keep in mind what is important to them and why they may be seeking a n position ? this will help you highlight areas of impor in your position advertisements and interviews.

Ask in g t h e Righ t Qu est ion s Fin din g t h e Can didat es An experienced recruiter is likely to have interviewed hundreds of candidates. As a result, recruiters know how to draw out the candidate and identify less qualified candidates. For example, by employing deliberate, intentional questions, they can filter out the ?fluff ?? so to speak ? to get the story behind why the candidate is leaving their current position or get a good sense for what their potential may be.

The unemployment r at e as of April 2019 is 3.6 percent. With unemployment at its lowest since December 1969, many employers are struggling to find qualified candidates. Professional recruiters can leverage their experience and provide access to candidates that would be difficult for a practice to obtain otherwise. For example, an outside recruiter generally maintains a large network. Their connections keep them informed of qualified candidates looking to enter the job market or change jobs. A competent recruiter will know which doors to knock on and where to find up-and-comers as well.

Moreover, candidates often feel more comfortable interviewing with the recruiters versus interviewing with the practice and may potentially share more about their previous experiences.

Recruiters also provide value by selecting the best job advertising platforms. Not only utilizing popular, well-known job boards, but also regional job boards and other platforms that practices may not typically consider in a candidate search.

It can be helpful to have the recruiter conduct the initial interview before the practice meets the candidate, as the recruiter can provide valuable insight and a professional opinion on the candidate?s personality, character traits, strengths and weaknesses, as well as how they may fit into the practice.

You may also save on advertising costs here as well? your recruiter may already maintain subscriptions to job boards and industry specific platforms (i.e. Medical Group Management Association, American Association of Nurse Practitioners ), and may only charge a nominal posting fee or include it as part of their service offering.

Salary discussions can also be handled beforehand, to ensure candidate?s salary expectations are in alignment with the practice?s budget. Candidates with different or unreasonable salary expectations will not slow down the process, as they can then be eliminated from consideration.

At t r act in g t h e Righ t Can didat es

Ch oosin g t h e r igh t f ir m

Since we are currently in an employee?s market, generating the right messaging about your practice is essential for staffing. An experienced recruiter will know how to sell and promote your practice?s attributes, thus making your practice an attractive opportunity for job prospects.

There are different types of recruiting firms, and it is important to understand the differences. Some firms are solely focused on recruitment and offer only these services to practices, even specializing in recruiting of specific staff such as support staff or higher-level administrators. Other

recruitment

s new ortance

Sou r ce: w w w.payscale.com

recruiters may work as business consultants and have a role in helping your practice in other areas outside of recruiting, giving them a broader picture of your practice and its needs.

contracts. They can also help with background checks or conduct the full on-boarding process to make sure that the candidate is seamlessly integrated into their position. Now that you have your employee in place, you can begin the work of keeping them! Employee turnover can cost the practice even more than the recruiting process. Read about the true cost of employee turnover here: www.verdenviewpoint.com

Addit ion al Valu e Recruiting firms can also provide valuable services after a candidate has been hired. For example, they can provide templates or suggestions with letters and employment

Regulatory Changes 12

under theradar: medicare, medicaidPayment model trends Susanne Madden, MBA, CCE Founder & CEO, The Verden Group

Since DHHS Secretary Alex Azar announced in January 2019 a proposed rule to both offer drug discounts directly to consumers and disallow drug manufacturers from providing rebates to PBMs, curtailing drug costs has been the focus of national healthcare policy attention. As a headline in the Wash in gt on Post on February 1, 2019 noted, ?The Trump administration is taking on middlemen that inflate drug prices?. Indeed, the need to curb skyrocketing drug costs has been an area of general agreement between healthcare providers, hospitals, insurance companies, and the public. However, less attention has been focused on other Medicare and Medicaid payment changes emerging this year ? with potentially major impacts on physician practices, home healthcare and hospice agencies, and nursing homes. While not garnering as much public awareness as the proposed rule focused on drug-pricing, these changes will have broad healthcare system consequences. Described below are some of these payment changes, along with their potential implications.

payment model trends M edicar e?s Review Ch oice Dem on st r at ion (RCD) ? Im pact on Hom e Healt h an d Hospice Agen cies

financial risk arrangements; reporting systems in place to track and drive performance improvement; coordinated care across the continuum is embraced by physicians and other clinicians; provider network is developed to deliver high value.

June 1, 2019 is the date scheduled for the first of five CMS-selected states participating in the Review Ch oice Dem on st r at ion (RCD) aimed at reducing over-payments to home healthcare agencies (HHAs). It was the outgrowth of the CMS effort to reduce Medicare fraud. Illinois was allowed a choice selection period from April 17, 2019 to May 16, 2019, and HHAs were instructed to choose between the following three options: a) pre-payment review; b) post-payment review; and c) minimal review (?status quo?) with a 25% CMS payment reduction.

Only a small percentage of all ACOs currently participating in the MSSP accept two-sided risk, but this CMS rule change goes into effect on July 1, 2019. While an article in Healt h Af f air s in 2018 supports an eventual switch to two-sided risk as necessary for a federal shift toward value-based payment, it likewise suggests that two-sided risk entails more financial risk for some ACOs (e.g., rural ACOs) than other ACOs.

The other st at es select ed for this five-year period are Florida, North Carolina, Ohio, and Texas. In 2017, Illinois participated in the RCD?s predecessor project (PCRD) ? and expr essed it s f r u st r at ion with disruptive bureaucratic processes that adversely impacted the HHAs?functional capacity in Illinois.

Indeed, two additional categories of ACOs that may incur greater financial instability through assuming two-sided risk are small ACOs, and those that primarily serve impoverished communities. Meanwhile, an article published on May 7, 2019 in Du ke Today suggested that the three ACO characteristics most closely linked to a decreased risk of MSSP withdrawal are: ACO receipt of shared-savings bonus payments; ACO has high benchmark per capita; ACO has increased care coordination services

In addition to the RCD, another HHA-aimed CMS payment project ? the Hom e Healt h Pat ien t -Dr iven Gr ou pin gs M odel ? will commence on January 1, 2020. This will involve a ch an ge in the unit of home health payment to a 30-day period and significantly differs from the current bundled-payment system based on a 60-day episode.

Feder al M edicaid Regu lat or y Ch an ges f or St at es Ch an ged Risk Requ ir em en t in M edicar e Sh ar ed Savin gs Pr ogr am

In a recent Pew Ch ar it able Tr u st s article titled ?Trump Greenlights Major Medicaid Changes?, the author describes how the Trump Administration is approving requests to cut back on Medicaid-covered services. While Trump appointees?support for adding a work requirement to existing state eligibility requirements has received more mass media attention, the CMS under Seema Verma?s leadership is approving states?requests to both curtail benefits and reduce the number of applicants eligible for Medicaid.

In December 2018, the Centers for Medicare and Medicaid Services (CMS) f in alized a r u le that requires Accountable Care Organizations (ACOs) to take on more risk or be dropped from the Medicare Shared Savings Program (MSSP). The National Association of ACOs (NAACOS) has strongly opposed the regulatory change within this finalized rule that requires newly-formed ACOs (i.e., Track 1 ACOs) to also assume downside risk akin to that shouldered by more stable and longstanding ACOs. Furthermore, NAACOS ar gu es that this increased requirement for two-sided risk ?could significantly undercut the ability of ACOs to flourish individually and collectively?.

President Trump has particularly expressed his approval for a r u le ch an ge proposed to ?public charge? policies on October 10, 2018 that is focused on legal immigrants. This rule change would legalize denying them Legal Permanent Resident (LPR) status (i.e., a ?green card?) if these immigrants apply (or received) Medicaid or other federal ?safety net? benefits. Additionally, this rule change would deny them entry into the US.

However, some healthcare finance researchers have suggested the following as com m on ch ar act er ist ics of ACOs that have been successful in transitioning to two-sided risk: ACO executive and physician leadership embrace value-based care; systemic administration of

Fifteen states have applied for federal approval to require their Medicaid beneficiaries to work, and the following have

payment model trends

"Given President Trump?s acknowledgment of the opioid epidemic as a public health crisis, the hypocrisy of granting Medicaid waivers that would likely require opioid addicts in day-treatment programs to work or lose their Medicaid eligibility is astounding."

already received their waivers: Arizona, Arkansas, Indiana, Kentucky, Missouri, New Hampshire, Ohio, Utah, and Wisconsin. However, federal judges have thus far blocked (or halted) most from implementation.

Tr u m p?s ?Con scien ce Ru le? an d t h e Im pact on LGBT Pat ien t s On May 2, 2019, a DHSS r u le expanding the capacity of healthcare workers to deny care to patients on religious grounds was announced. While this regulation is not specifically related to Medicare, Medicaid, or payment reform, its implications are so enormous that it needs to be included in considering the scope of healthcare system changes this year that have occurred ?under the radar ? for most Americans.

Given President Trump?s acknowledgment of the opioid epidemic as a public health crisis, the hypocrisy of granting Medicaid waivers that would likely require opioid addicts in day-treatment programs to work or lose their Medicaid eligibility is astounding.

Paym en t Ch an ges t o Nu r sin g Hom es (Sk illed Nu r sin g Facilit ies)

Senior-aged LGBT people have long experienced the impact of discrimination in their lives, and this regulation promotes the continuation of this discrimination just as they are most in need of more compassionate healthcare services.

On April 19, 2019, a f in al r u le was issued by the CMS updating ? in concordance with the Patient-Driven Groupings Model ? Medicare payment rates for SNFs (nursing homes). While the purpose is to shift nursing homes toward a value-based payment system, the Cen t er f or M edicar e Advocacy suggests that the financial incentives under this rule are configured in a way that higher reimbursement to nursing homes is tendered when a resident receives no type of therapy ? rather than when some type of physical (or other) therapy is provided.

Con clu din g Th ou gh t s ? Tr u m p?s Wide-Ran gin g At t ack on t h e Nat ion?s Healt h Not every Trump Administration healthcare-related policy has generated broad public comprehension or awareness. Indeed, some policies promoted by the Trump Administration affecting healthcare access are more destabilizing than others. However ? taken as a whole ? these policies demonstrate a poorly-conceived vision of a US society that is health-promoting and assumes responsibility for the well-being of future generations.

Nearly 50% of nursing home residents (and 32% of HHA clients) have Alzheimer ?s disease, as r epor t ed by t h e CDC. Whether someone has Alzheimer ?s disease, Lewy Body dementia, prefrontal lobe dementia, or some other dementia form, participating in activities that require problem-solving at an early stage can slow the progression of dementia.

Historians twenty years from now may yet record the coming year as the time we let our president and his cabinet appointees harm our children?s chances of attaining a healthy old age.

In addition, depression often accompanies increased social isolation (as often occurs in wheelchair-bound residents in nursing homes), and depression can likewise worsen dementia. Therefore, de-incentivizing nursing homes from providing occupational or recreational therapy to residents can lead to more rapid cognitive decline.

practiceBil l ing: in-housevs. outsource Brandon Betancourt, MBA & Dr. Seth Kaplan, MD

A question that gets asked frequently is whether a practice should have their billing department in-house or if outsourcing is a better option. Much like discussions about Cubs vs. Whitesox, Yankees vs. Mets, and Ford vs. Chevy, the answer is not always clear. People passionately argue equally for both in-house and outsourced billing. In the blue corner, you have the in-house billing crowd. They contend that an internal billing department will always do a better job of staying on top of claims, and collections, than a billing company. In the red corner, you'll find practices that have had a hard time hiring and keeping qualified billers. Others have had experienced billers quit without notice, go

practiceBILLING on maternity leave, and not come back, or been victims of embezzlement at the hand of billing personnel resulting in financial hardship. These practices argue managing their billing in-house can be both a burden and a liability. Indeed, each practice's experience supports their views and opinions. I recently caught up with Dr. Seth Kaplan to talk about his experience with billing. Dr. Kaplan is a solo-independent physician in Frisco, TX, and he has been on both sides of the in-house vs. outsourced billing discourse. I invited Dr. Kaplan to recount -- for the Verden's ViewPoint readers -- some of the challenges he has encountered with his practice's billing. I also asked him to provide insight into what he did to adapt to the circumstances and how he managed to work out these issues. Below is his story: When I opened my practice almost 15 years ago, I was determined to start with in-house billing. My office manager served in this position. Frankly, she was a much better biller than an office manager. She did a fantastic job on the billing side, but a pretty lousy job on the office manager side. Since I was small (just me, eventually adding a part-time MD), this arrangement worked fine for a time. About two years after I opened, my office manager/biller decided to leave for another job and I was left in a lurch. My wife had been trained to do the billing, but she absolutely hated every aspect of it and for her to continue in this role would have been the end of my marriage. Meanwhile, billing was not being handled well, and nobody else in my office wanted any part of it. Not knowing what to do, I turned to a friend who worked for a billing company. He helped me get going with billing on my own and soon after that, I ended up hiring the company he worked for to help us get through this difficult time. During this time, I hired a new office manager who was fantastic but not a biller. Unfortunately, I could not find another suitable billing person And, frankly, it was a relief to be able to farm this out. Our office established a strong working relationship with this billing company. In turn, we taught them a lot about pediatric billing issues, which they took on with gusto. 18

Enter 2011, and the 5010 transition was looming. I was also unhappy with the EHR I had at the time and was looking to make a switch. Ultimately, we decide to go with PCC?s EHR, which also meant transitioning our billing to PCC?s practice management?s system. My old billing company only worked with GE Centricity (our former PM, which hadn't been updated since we went live in 2003 and was going to require $25000 in upgrades to get it 5010 compliant) and Aprima. We approached our billing company to see if they would be willing to take on another PM system. They looked at PCC?s practice management system and decided they couldn't do it. So, we were left with what to do. We were on good terms with the old billing company but needed a new solution. We looked at bringing billing back in-house but could not find a biller we thought was worth hiring. Our transition date was approaching, and PCC wanted to know what we were going to do so that they could train a new person if needed. At the same time, we were dealing with other pressing issues. We were relocating our office, starting to think about becoming a certified medical home, and beginning to explore the Game of Thrones style transition that was taking place in the Dallas marketplace (that's a story for another time). Ultimately, we decided to use the billing company that PCC recommended. It was a tough transition at first, but it eventually became a very productive relationship. The old billing company agreed to work all claims up to the date we went live with the new software. We considered hiring an in-house biller again when our contract with the billing company expired, but in the end, we decided we were happy to farm this out. It?s one less stress for a small office that was dealing with massive changes that were coming at us fast and furious. A few years later, our practice joined a larger entity and they had a billing department. So we made another transition. Ultimately things did not work out, and I ended up being independent again. A front office employee that had been with us for a long time expressed interest in doing some billing. This staff 19

practiceBILLING member had been doing some billing training already and was interested in shifting to a primarily billing role. My office manager felt that between herself and this staff member (and the support of PCC) we could successfully do billing in house. And they were right! Bringing back the billing in-house has worked out well, but I?ve learned that it's all about having the right people at the right time. Dr. Kaplan's billing saga adds an insightful perspective to the argument. To answer the question, maybe we ought to frame the issue differently. Perhaps, we should consider that the issue isn't about location alone (e.g., where is billing located) but rather, where are the right people, with the right resources, and with the right skills?

Dr. Seth Kaplan is the owner of TLC Pediatrics in Frisco, Texas. Dr. Kaplan attended the Duke University School of Medicine. He completed his pediatric training at Boston Children's Hospital (Harvard University) and Boston Medical Center (Boston University). Dr Kaplan is board certified in pediatrics. w w w.t lcpedsf r isco.com

ISAPEORIGHTFOR your practice? Heidi Hallett Writer & Contributor

Managing human resources is time-consuming and highly specialized work which is why many small businesses turn to outsourcing. Outsourcing HR functions not only free up time and energy of existing staff and practice owners, but it also ensures that HR matters are handled appropriately, efficiently, and in accordance with best practices and the law.

Wh at is a PEO? A Professional Employer Organization (PEO), is a one-stop shop for the HR needs of small businesses. PEOs offer a suite of services from payroll and tax management, benefit claims and health insurance administration, to many HR functions. Most small business owners didn?t get into business because they?re payroll wizards or because they love filing tax forms. Most people go into business because they have a specific set of skills to share and a passion for what they do. Sound familiar? Chances are if you?re a physician who owns (or is a partner in) a practice, you chose this career path so you could help patients, not so you could learn how to calculate payroll deductions. 21

PROFESSIONALEMPLOYERORGANIZATIONs

?I chose JustWorks as our PEO because payroll and associated HR functions ca company significant money on worker and employer insurance. JustWorks all of benefits to our employees including disability, and various other perks.?

- Susanne Madden, Founder & CEO, The V What is a PEO? JustWorks explains:

When you outsource these tasks to a PEO, they essentially become the employer to your employees?? you still run the business and your staff answer to you, but your PEO handles everything relating to payroll, taxes, and benefits. Some PEOs will also manage incentives, employee benefits, and perks such as access to 401(k) plans, discounts on public transportation and other commuter benefits, or bulk discounts for wellness perks such as meditation classes or gym memberships.

hesitate at the thought of paying someone else to manage your employee services, consider both what it would cost to hire a trained professional in-house to do this and the cost savings that a PEO can offer you on health insurance plan fees and more.

Wh at does a PEO cost ? Is it w or t h it ?

A PEO does a lot more than issue paychecks to your regular employees; they?ll handle payments to vendors, contractors, casual and temporary staff, as well as taking care of automated deposits, vacation payments, and expense reimbursements.

Wh at can a PEO do? Payr oll M an agem en t

Like all professional services, PEO fees can vary greatly. Most PEOs calculate fees based on the number of employees, your location, and business credit scores. Costs per employee can range from $99/month to upwards of $200 depending on which PEO you choose and what services you require. Other factors such as past Workers Compensation and benefits claims history may also contribute to the calculation of your fees. Before you

Ben ef it s & Savin gs PEOs offer access to competitive rates for medical, dental, and vision coverage for your team because they can

Wh at a PEO Doesn?t Do Also, as a general rule, PEOs aren?t legal or tax advisors. While they can help with any number of forms and filings, as well as support, each company still needs to be familiar with the laws applicable to their business and be responsible for compliance.

PEOs can take on much of a business?s administrative burden. However, they can?t do it all. It?s important to note what a PEO generally will not do. First, although co-employment allows the PEO to take over many responsibilities for their customers, they won?t take over the running of your business. It remains up to each employer to manage their team and their operations.

Source: ju st w or k s.com

Soundtoogoodtobetrue?

e I loved the efficiency with which an be done. They saved our small r's compensation, health care benefits lowed us to offer a much wider range g life insurance, short and long term

We ask ed t h is qu est ion abou t PEOs in 2016. Her e?s w h at w e h ad t o say: It ju st m igh t be. Th at ?s w h y it ?s essen t ial t o do you r r esear ch . Th er e ar e pot en t ial dr aw back s, in addit ion t o t h e ben ef it s PEOs claim t o pr ovide. Her e is a list of t h in gs t o t h in k abou t bef or e you m ake an y h ar d an d f ast decision s:

Verden Group

Ar e you r eady t o r elin qu ish con t r ol over par t s of you r m edical pr act ice? If you r clin ic f eels lik e you r ?baby,? it m igh t be h ar d t o let go of cer t ain aspect s of con t r ol. Alt h ou gh you w ill

typically apply the negotiating power of larger companies by grouping employees of many small businesses together. In addition to negotiating lower rates for your benefits plan, PEOs handle the administration of benefits-related paperwork and offer easy to use self-serve online tools making it easy for your staff to access and submit information and paperwork relating to their payroll and benefits.

st ill be ?t h e boss? w h en it com es t o you r act u al bu sin ess oper at ion s, som eon e else w ill be in ch ar ge of m ost of you r em ployee-r elat ed act ivit ies. How does t h is f eel w h en you t r y it on f or size? Have you t h ou gh t abou t w h at ef f ect t h is w ill h ave on em ployees? Som e em ployees m igh t f eel u n com f or t able w it h a t h ir d par t y, of f -sit e

Com plian ce Su ppor t

h u m an r esou r ces con t act . How w ill you r A PEO will take the stress and guesswork out of your employer-related compliance needs. No more worrying about payroll taxes, employee tax forms, and reporting. Different PEOs offer different support, but you can expect most to handle new hires, WCB, W-2, and 1099 filings, as well as matters relating to UI and EPLI.

em ployees r espon d t o a m or e ?im per son al?

Decr ease Risk s, In cr ease Pr odu ct ivit y

f u ll ou t lin e of all f ees an d ser vices, in w r it in g.

appr oach ? Have you don e you r h om ew or k ? Each PEO h as a dif f er en t pr icin g st r u ct u r e. M ak e su r e you f in d ou t w h at you ar e payin g f or an d ask f or a You don?t w an t t o get bu r n ed by h idden cost s.

Has your practice ever been fined for making payroll errors? If it has, you?re not alone ? 33% of small businesses get penalized every year for payroll mistakes. With over 15,000 often-changing tax codes, its no wonder costly mistakes are made. PEOs are compliance experts who know what paperwork needs to be filed and when.

Ar e you clear abou t liabilit y? PEOs assu m e som e of you r liabilit y (ie., t axes, payr oll, an d ben ef it s), bu t n ot all. It 's essen t ial t o k n ow t h e f act s. Ask an y PEO you ar e con sider in g w or k in g w it h f or det ails on liabilit y, in w r it in g.

Th e Valu e of You r Tim e

To r ead t h e f u ll ar t icle click h er e: w w w.ver den view poin t .com

Running your medical practice takes up a lot of your time. Most practicing physicians, if not all, wish they had more time to spend on patient care rather than on the business. Signing on with a PEO can free up valuable time so you can focus on what matters most to you ? your patients.

Theimportanceof activel istening Doug Gray, PhD CEO, Action Learning Associates

Communication problems abound. The number one complaint from leaders and managers is "poor communication." Today, effective communication is more important than ever, and developing active listening skills is a necessity in all aspects of one's professional and personal life. You can learn to be a better active listener. Active listening is a skill that anyone can develop with practice. Active listening is a fundamental interpersonal communication skill that helps leaders, administrators, and managers be better communicators and problem solvers. Active listening is not the only key to a pleasant conversation and genuine, empathetic engagement, it also has the potential to increase positive emotions. I often say, "A good conversation is as stimulating as dark coffee but more memorable." Why is that? Active listening can increase our subjective well-being and provide greater life satisfaction.

activel istening careful to state feelings only - not judgments when reflecting emotions to another person.

Th r ee Levels of List en in g There are three levels of active listening:

TIP: Ask something like, "If I understand you correctly, you are feeling (emotion) because of (action/event). Is that accurate?"

Level 1: Internal listening (e.g., the speaker is looking inside, but the listener may be listening to how that story affects the speaker)

Ref lect ed M ean in g Level 2: Focused listening (e.g., the listener is laser-focused on the speaker 's agenda)

To establish rapport between a leader and a colleague, or between a speaker and listener, is through reflected meaning. Reflected meaning focuses on the factual message of the speaker instead of emotional communication.

Level 3: Global listening (e.g., the listener is focused on global cues, including intuition, emotions, body language, or the environment.) Do you notice the differences? Now reflect on that last conversation you had with a partner, colleague or employee. Was it at level 1, level 2, or level 3?

As an example, use data or facts to build your case like a lawyer. State only the facts, and include numbers, dates, and details. The result of repeating those exact details is that the listener nods their head as if confirming understanding with the speaker.

Types of Act ive List en in g In addition to those three levels of active listening, there are four main types of active listening that require the listener to hear, evaluate, and interpret the content of speech. You can practice each of these techniques.

TIP: Consider using the following question to employ reflective meaning "What I?m hearing is that when (action) occurs, you feel (emotion) and want to do (new behavior or action). Is that accurate?"

Par aph r ase

Su m m at ive Ref lect ion

One way to develop empathy and practice active listening is by paraphrasing. The listener repeats the essence of the message spoken by the communicator using their own words. This demonstrates that the listener is actively concentrating on the narrative the communicator is trying to convey.

Summative reflection includes a confirmation of the message content. This technique strengthens interpersonal ties and promotes efficiency in the communication process. Summative reflection combines elements of paraphrasing, reflected meaning, and reflected emotion, and requires the listener to incorporate personal views into the communicator 's message.

Paraphrasing can be the most challenging active listening technique to perfect as it requires skill as well as discipline.

While summative reflection can be the most challenging type of active listening to exercise, it is the most powerful.

TIP: Record your paraphrase using your smartphone. Then share it with your colleague and ask, "Is this an accurate paraphrase?" It works.

TIP: Take notes when you?re having important conversations so that you can accurately summarize the essential details and validate the other person?s concerns.

Ref lect ed Em ot ion s Another technique that practice leadership can use to improve upon active listening involves reflecting the feelings of the communicator. This type of active listening establishes an emotional rapport between the communicator and the listener.

Active listening techniques can be learned and get better with regular practice. Consider outsourcing a coach to help you and your team become better listeners and better communicators all around. Bringing active listening into your medical practice will help build relationships, solve problems, resolve conflicts, and improve morale.

Be careful when using this technique. Emotions describe another person's state (e.g., mad, sad, glad, happy). Judgments or opinions are not the same as emotions. Be

SUPPORTING INDEPENDENT PRACTICES For your pract ice t o st ay independent , you need access t o: -

Lowest cost Medical Supplies: pricing that usually only larger practices & organizations can demand Highest Vaccine Rebates: the lowest acquisition costs + highest rebates Choose from a ranges of expert services & products at the best prices and highest levels of service to support your practice Contract Management, HR, Compliance, Grant Sourcing and more

WE MANAGE YOUR COSTS AND SERVICES, YOU MANAGE YOUR PATIENTS. Find out how you can join here: www.IPMSO.org powered by

Spotl ight: bil l ingtransition Brandon Betancourt, MBA Practice Management Consultant

In 2017, after 30 years of managing his billing in-house, Dr. Peter Liber decided to transition to an outsource billing company. I sat down with Dr. Liber to learn more about his practice, the circumstances behind the move, and how the journey has gone for him and his practice.

last year, we merged into a pediatric supergroup, PediaTr u st. We became Pediatrust's 12th practice. Br an don : How many total doctors do you have now? Dr . Liber : We have six pediatricians and two nurse practitioners, a total of five and a half full-time equivalents.

Br an don : Dr. Liber, thank you so much for taking the time to speak to me today.

Br an don : How about your insurance distribution, do you have an estimate in terms of the percentage of private versus HMO versus Medicaid?

Dr . Liber : The pleasure is mine. Br an don : Tell us a little about your practice. Dr . Liber : We're a suburban general pediatric practice that I started from scratch in 1987. I was a solo practitioner for approximately three years. Then I brought on a part-time pediatrician. A year or two later, the part-time pediatrician became a full-time pediatrician. We've been growing ever since. About five years ago, we opened a satellite office about 13 miles west of our original location. Early

Dr . Liber : I would say approximately 85-90% private. About 5% HMO, and about 5-10% Medicaid. Br an don : With the HMOs, does the practice belong to an IPA? Dr . Liber : Yes.

spotl ight: bil l ingtransition Br an don : What EMR does your practice have?

outsourcing was a result of joining the supergroup. Not because you identified issues with your in-house billing?

Dr . Liber : We were with eCW (eClincalWorks) for approximately 11 years, and about seven months ago, we switched over to Epic.

Dr . Liber : Correct. It was a decision made for me. It did not make business sense to continue to do in-house billing, especially with the impending transition to a new EMR.

Br an don : I'm curious, how did the transition from eCW to Epic go?

Br an don : How did the transition from in-house to outsourcing go?

Dr . Liber : Not as bad as I had anticipated. It was much smoother than going from paper to eCW. My supergroup partners helped with the transition before and after go-live. The front desk also transitioned well. In fact, seven months in, I like Epic.

Dr . Liber : The latter half of 2017 found our billing department short staffed. Some of the in-house billing staff had personal health issues, and others moved on, which disrupted our billing efforts. The transition brought to light pitfalls of our current in-house situation. The billing company that took over was instrumental in helping clean up some of the unfinished business that was left over from the last few months of the old in-house system.

Br an don : What do you like about Epic? Dr . Liber : A few features stand out. Ease of remote HIPAA compliant access, the potential for template sharing and customization, but the feature that stands out is the ability to share patient medical information. Most of the health systems surrounding us are on Epic as well. So the Care Everywhere feature is terrific in helping with the transition of care for our patients.

Br an don : Were you aware of the billing inefficiencies as a result of the personnel issues, health issues? Dr . Liber : These issues prompted us to switch sooner rather than later. We outsourced our billing before the transition to the supergroup. The outsourced company took over about a month before the merger with PediaTrust.

Br an don : You mentioned you started as a solo doc. How did you handle the billing when you first started? Did you start with a billing company, or did you do it in-house? Dr . Liber : Until the past 18 months or so, it's been in-house.

Br an don : Did you see fluctuations in the receivables or a drop in claims being filed while the personnel issues and challenges were occurring?

Br an don : How many billers did you have? Dr . Liber : We had one full-time biller and two to three part-time billers.

Dr . Liber : I didn't see them at the time, but it was definitely apparent once the new billing company took over. As they continued to work our account, the problems were evident. Given our staffing issues, the outsourcing company was able to dedicate more resources to clean up the mess.

Br an don : Seeing that you had the billing in-house for 30-years, can I assume everything was working well?. Dr . Liber : I was happy with our in-house performance. I had an independent audit three years ago, which confirmed this. Our in-house billers were not a weak link.

Br an don : A short-staffed billing department is a problem that many practices run into.

Br an don : Let's talk about the events that led to the decision to move the billing to an outsourcing company in 2017.

Dr . Liber : If you have the equivalent of two full-time billers, and one of them is out, or one of them ineffective, that really is a huge disruption with quite a ripple effect to the bottom line.

Dr . Liber : As stated earlier, we joined the pediatric supergroup PediaTrust on January 1, 2018. PediaTrust uses an outsource billing system named Sper oM D; so our billing was also transitioned to the billing service.

Br an don : I'm glad you brought this up. One of the upsides of working with a billing company is that they have the flexibility to increase capacity. If work increases, more claims need to go out, or a new physician is added, they're

Br an don : The decision to go from in-house billing to

spotl ight: bil l ingtransition able to allocate more resources, and the practice doesn't experience any disruptions financial or otherwise.

other half is patient responsibility. Is your billing company proactive with collecting patient balances and calling patients when there are issues?

Let's talk about the work SperoMD, PediaTrust's billing company did for the practice. You mentioned the transition to SperoMD was prompted by staffing issues, and not necessarily because of problems with the billing. However, SperoMD identified problems with your practice's billing.

Dr . Liber : That's an important part of service. When the patient comes in, those issues are discussed face to face. But the statements are sent out by the billing company. Br an don : If a patient calls the practice with a question about their bill, do your staff handle them, or do billing inquiries get sent to the billing company?

Dr . Liber : We had periodic auditing of the billing system by my accountant. But we had not been doing that the last few years. In retrospect, I realized there was a lack of adequate oversight.

Dr . Liber : It depends on the issue. I think inquiries are handled at the office first. Then after that, if the question can't be adequately answered, it's routed to the billing company. If I had to guess I would say probably 40-50% of the calls that come in are handled in-house and the rest are sent out.

Br an don : Do you remember the problems the billing company identified? Dr . Liber : So, there were overpayments that weren't handled as effectively as they should have been. That needed to be corrected. Claims weren't going out as promptly as they should have. Certainly not as quickly as it has been since outsourcing.

Br an don : A couple of points that I think are worth highlighting. The first one is, even though the practice has outsourced billing, the office still has billing responsibilities. Your comment about your staff handling questions right then and there, either on the phone or face to face, as opposed to referring the patient over to the billing company is an excellent example of delivering good service. The second point is the importance of training the front desk to answer billing questions. Referring all billing inquiries to the billing company ? or the billing department, for that matter ? can cause all kinds of delays and issues.

Br an don : Did you see immediate improvements? What were the results? Dr . Liber : The result is that the payments are coming in much quicker, in a more timely manner than ever before. So it's been beneficial there. Br an don : Clearly, it has been a pleasant experience for the practice in many ways. You have resources that can be allocated if necessary. Also, you have the oversight that you didn't have before. It sounds like things are running a lot more efficiently.

Dr . Liber : Yes. And the personal touch is still there with those billing issues. Br an don : We talked about some of the great things the outsourcing company does for the practice. Have you encountered any challenges during the transition or even currently?

Dr . Liber : Correct. The coding, for example, I have more confidence in doctors coding correctly because our outsourced billing vendor reviews each claim before they send it out. SperoMD coders review each encounter note and verify that the proper documentation and level of coding match up.

Dr . Liber : Correct.

Dr . Liber : Well, the other 40-50% of patient billing inquiries are out of our hands. It's important to make sure that the representatives in the billing company are treating our patients with the same respect that we treat our patients. That's a challenge. To my knowledge, there haven't been any complaints about that. Since that question isn't answered under our roof, we want to make sure that everyone's on the same page in terms of handling different billing scenarios and issues.

Br an don : Billing companies handle the insurance portion of the billing. However, that's only half of the process. The

Br an don : What about the cost of hiring a billing company, any thoughts about that?

Br an don : SperoMD has experts that review your charting to make sure the coding is adequately aligned with the documentation. This is a service that the billing company provides?

spotl ight: bil l ingtransition Dr . Liber : At our practice, outsourcing the billing is almost twice the cost of our in-house billers, when you factor in salaries, benefits, and IT costs. However, I suspect that the expense is outweighed by correcting the efficiencies in collections and the improved coding, and improved reimbursement that has resulted from the change. I can't give you an exact dollar amount, but I think it's a net gain on that front.

Every leg of the practice should be equally strong. Sometimes you need the help of an outsourcing company to do that. In my case, I think it was a good thing. It might not be right for everyone. Br an don : "The billing has to be as good as the clinical piece." I think that's an excellent point. In addition to the lack of oversight and having a competent manager are there other lessons you learned along the way during this process that you'd like to share?

Br an don : Excellent point. I often talk with clients about the cost of things and the value of things. I explain that cost is what you pay; value is what you get. When you compare the cost of outsourcing the billing with payroll, many get sticker shock, step back, and don't consider any potential upside. However, in your experience, the confidence you have with your coding, the efficiencies that are in place to get paid faster is added value. It's hard to quantify value, but if you consider the amount of money that was lost and the downside of going without the added benefit, it puts the cost into perspective.

Dr . Liber : Don't hesitate to ask for help. Don't hesitate to get an outside person to take a fresh look at the billing piece of your practice. I think that an independent auditor or a consultant someone like Paul Vanchiere or Susanne Madden from the Verden Group can do that. I suggest the practice get somebody who's focused on your specialty and assessing that piece of your practice. Also, practices should probably do assessments randomly, once a year, once every other year, to make sure they are doing all the right things.

Dr . Liber : You don't want to think about that, but you do have to think it through to realize that cost is not the only thing to consider.

The other thing is keeping up on the latest coding changes. That can be a challenge if you're in-house. I think if you've got an excellent billing company, they should be on top of those things and they should make any changes automatic.

Br an don : It seems that the consensus among private practices is that billing companies do not do as good of a job as an in-house billing staff. What are your thoughts, or what would you say to people who are very firm on that belief?

Br an don : What about the AAP's coding hotline? They are a good resource. Dr . Liber : I love the AAP coding hotline. But sometimes you want an answer right away. Now, I pick up the phone. I call my billing company and get the answer in real time. I do that once every few weeks, not every day. But it's good to have that expertise available.

Dr . Liber : Those people probably have a very efficient, smooth running billing staff who are up to date, who are healthy, who are totally committed to the practice, and have skin in the game. My advice to them is to start their own billing company with their staff. Because if they're doing such a good job, then there are a lot of people out there that aren't.

Br an don : I have one final question for you. What was something that you thought you knew about outsourcing and practice billing that you later found out you were wrong about?

If you think your billing staff is functioning at a high level, it would be wise to get an independent agent to audit your billing and your coding practices periodically. An audit will likely uncover issues that, when corrected, will more than pay for the inquiry. A good practice manager hopefully will sustain the corrected issues by holding all parties accountable. Most pediatricians are not formally schooled in medical practice finance. We learn by trial and error. Along the way, inefficiencies pop up. The billing function of a practice must run efficiently and effectively. You want the billing piece to be as good as the clinical piece.

Dr . Liber : I thought that paying more for outsourced billing services was unnecessary, that we could do it better in-house. I was wrong. The extra services and efficiencies are more than worth it. Dr. Liber, a native of Gary, Indiana, has been practicing pediatrics since he founded Wheaton Pediatrics in 1987. Disclaimer: SperoMd is a subsidiary of PediaTrust. Dr. Liber owns a minority interest in PediaTrust.

social media: shoul dyouhireanexpert? Noreen Quadir Social Media & CommunicationsSpecialist

Social media is one of the best and most cost-effective ways to stay connected with patients and promote your practice. In today?s connected world, prospective patients look to social media to learn more about medical practices and read up on doctors?reviews before choosing a provider. Social media makes updating patients on office news such as closings, schedule changes, new insurance providers, vaccine information, and new services fast and easy. When compared to radio and print, advertising on social media allows you to target your campaigns specifically to your audience (potential patients at a lower cost). Investing in social media is investing in your practice and should be an essential part of your overall marketing budget and plan. As beneficial as social media is for your practice, finding the time to do it and to do it well is not easy when you?re busy running your practice and taking care of patients. Your office manager or receptionist could manage the clinic?s social pages, but it's likely they too are busy performing office duties.

Looking to existing team members may seem like the right solution, but they may not be skilled in social media marketing, or they simply may not like it. Unless you have a tech-savvy staffer who is already a social media wiz, your best option is outsourcing social media responsibilities to experts. A social media manager typically has a background in marketing and communications, writing and creative skills, knowledge of all the different platforms, and how best to put them to use. Experts in social media management also keep up to date on the latest trends and changes, and they have a strategic mindset and an understanding of how to represent brands online. The best social media managers are passionate storytellers with a talent for connecting with the community. A social media manager can help determine which platforms your practice should be active on and which ones may not be the best fit. They will advise you on which networks have the best tools for reaching your audience and ensure consistent messaging to prospective and existing patients. Outsourcing your social media takes a lot of the guesswork out of it, which saves you time and money. A social media manager will work with you on establishing goals and develop social strategies and targeted campaigns to achieve those goals. In addition to keeping your social media pages updated regularly, an outsourced expert can devote the time needed to research articles and information from reliable sources to share, craft copy, and publish engaging content. Sharing these updates will also help establish your practice and providers as experts in the field and keep your followers interested in your posts instead of scrolling past them. Social media managers also know the best and worst times to post based on analytics and trends. Once a post is live, a social media specialist can help keep track of comments and messages and take appropriate and timely action. If there?s a message that requires your attention, the social media manager will contact you directly to let you know. It?s a good idea to have a plan on how to respond to any negative, aggressive, or inappropriate comments from followers. A speedy reply telling them that someone from the practice will be in touch with them in a pre-determined timeframe will go a long way to defusing any unpleasant social media interactions. 33

social media In addition to monitoring comments on posts and private messages, a social media manager will also track reviews left by patients. Online reputation is now a vital component of a practice?s potential success. If a negative review is posted, it should be noted and addressed as soon as possible. A social media manager will not only monitor reviews on your behalf, but they will also advise you on best practices for damage control so that your practice maintains a positive online presence.

PROTIP Take ph ot os an d videos of you r pr act ice an d st af f t h at illu st r at e t h e f r ien dly an d w elcom in g en vir on m en t of t h e clin ic an d sen d t h em in a bat ch t o you r social m edia m an ager . High ligh t an y special f eat u r es in you r clin ic, celebr at e a t eam m em ber ?s bir t h day, or sh ow of f you r Hallow een cost u m es! You r social m edia m an ager can t h en cr eat e a plan f or t h e best days an d t im es t o post t h em .

Moreover, if your office is going through some changes such as a provider leaving, they can create a proactive plan for making announcements in a way that will cause the least amount of negative feedback and still highlight the things that are positive for your practice. When it comes to getting the most out of your social media, knowing how to track social metrics and take advantage of analytics is key to success and often best managed by an expert. They?ll see what types of posts receive the most traction and use that data to inform future posts. Paying attention to social analytics is very valuable for enhancing marketing strategies, and your social media manager can advise you on the type of content that is worth producing.

As you work with your social media manager, you?ll build a compelling tool kit of media assets while also being able to monitor the progress and make adjustments if and when needed to get the most out of your advertising budget. If you have competitors in your area, a social media manager can provide another great advantage. You may want to have them perform a competitor analysis as they can evaluate the social pages of your competitors, see how they?re engaging with the community and which posts patients take an interest in, as well as their overall online reputation. This can produce insights that your social media manager can take into consideration for representing your practice online and sharing content.

Aside from strategy development, content publication, and audience engagement, there are many types of ad campaigns offered on social platforms that could be suitable investments for your practice. Paid campaigns can be useful for: -

driving people to your practice website promoting the services offered at your practice introducing new providers and staff increasing views on a post or video getting responses to an event that you?re hosting or growing followers, and ideally, patients

Social media is continuously and rapidly evolving. For example, Facebook started as a community platform exclusively for Ivy League students that quickly became an influential, global multimedia platform. When Twitter launched, tweets had a 140-character limit including images and other media, whereas they now allow up to 280 characters, excluding media.

Social media managers are skilled and knowledgeable in effective advertising and they often have other creative skills such as photo and video editing, website and graphic design, public relations and SEO. They will determine which types of campaigns are worth doing based on your goals. They can target the ads to specific demographics that represent your patients and within your geographic community. This type of targeted social media advertising often nets a more significant return on investment than traditional advertising mediums such as magazines, newspapers, flyers, and radio and TV ads.

A social media expert keeps up to date with these changes and predicts upcoming trends so that they can share new strategies and ideas for getting the most out of each platform. Managing social media takes a good deal of time and energy, and the learning curve is constant. Instead of pulling resources from your existing team, hiring a dedicated social media professional allows you and your team to focus on the core of what you do ? treating your patients.

JOINUSAt THESE CONFERENCES&EVENTS thefutureof pediatric practice2019 -

August 30 - Sept 1, 2019

Lake Beuna Vista, Florida

Presenting & Exhibiting!

2019PCMHCONGRESS -

September 6-8, 2019

Boston, MA

Presenting & Exhibiting!

AAP2019national conference&exhibition -

October 25-29, 2019

New Orleans, LA

Presenting & Exhibiting!

EHRtransition: Taketwo Brandon Betancourt, MBA Practice Management Consultant

In 2017, Susanne Madden sat down with Dr. George Rogu of RBK Pediatrics to discuss how he and his team, integrated different software applications (i.e., EMR, Practice Management, Scheduling, et al.) into his practice. Watch the 2017 interview here: w w w.ver den view poin t .com During the interview, Dr. Rogu demonstrated the functionality of each software and how each application helped the practice be more effective and efficient. Moreover, he emphasized how each software application was configured to operate seamlessly with each other. Dr. Rogu also shared with Susanne that an all-inclusive software solution (i.e., one vendor that offers the EMR and Practice Management system) was not a good fit for their practice. Although Dr. Rogu acknowledged the challenges of working with multiple vendors, ultimately, he was confident that a hybrid model was the best option for his medical practice. Shortly after the interview in 2017 with Verden?s ViewPoint, Dr. Rogu received a call that would change everything. We recently caught up with Dr. Rogu to get an update and see what had changed since the 2017 interview.

ehr transition Br an don : Dr. Rogu, thank you for taking the time to have a chat with us again. Dr . Rogu : Always happy to chat with you, Brandon. Br an don : In 2017, Susanne Madden and you sat down for Verden?s ViewPoint technology issue to get a glimpse of your practice?s technology set up. I?d like to do a quick recap and briefly revisit the interview. Can you talk about the EMR and practice management system you had and how all the pieces came together? Dr . Rogu : We started with a practice management system in 1996. Then, in 2008 EHR systems were in vogue. Back then, there weren?t any all-inclusive computer systems. No one had it. So we found an EHR that was relatively good and interfaced well with our practice management system. Then we implemented a practice portal that integrated with our EHR system. Br an don : Was the portal a different vendor than the EHR company? Dr . Rogu : Third party, yes. And then we had a physician scheduler system that was integrated with the practice management system. Br an don : Sounds like you had a lot of moving parts. What were some of the challenges of dealing with multiple vendors? Dr . Rogu : One of the challenges is that only a few people know how everything works. Then if it breaks, nobody knows what happens, and vendors always blame somebody else. However, our vendors were outstanding. They always tried to resolve our problems. Br an don : You were a big proponent of your hybrid approach to technology. What were some of the things that led you to believe that this was the way to go for your practice? Dr . Rogu : Because it worked. I keep saying, if it works, do not change it. Why would I change my practice management if it's worked since '96 perfectly? As I said in the interview with Susanne, I am a big believer that if your system works, do not change it. I had a hybrid system where one company had the EHR, another company had the practice management, and the interface worked. 98% of the time, it worked well. Br an don : Some could argue that an all-inclusive system would work even better because everything is in under one umbrella, as opposed to working with multiple vendors.

ehr transition Dr . Rogu : I agree with that. If you're starting out, an all-inclusive would probably be the way to go. However, we were not just starting. We were adding on. It was like a house. You bought a home, you built, and then you built it more, and so on.

"RBK [Pediatrics] was like the Titanic. We were going to hit an iceberg. So we did everything in our power to steer away from that iceberg."

Dr . Rogu : I found out that our vendors were phasing out the hybrid model as we knew it. EHR and practice management software companies are moving away from hybrid models and focusing on all-inclusive solutions. My understanding is that this is an industry-wide shift. It makes sense. There is a significant upside to managing the entire user experience, and I?m sure it?s less expensive than maintaining hybrid models. Br an don : Did you end up evaluating Athena even though you weren?t fond of their business model? Dr . Rogu : I gave it a chance, an honest try. I looked at it, and after the demo, I said, ?This is so complicated it'll kill my productivity. I cannot figure out how to order a simple rapid strep; how am I going to do anything more than that?" I just gave up on it.

Br an don : Let?s turn the corner. About two years ago, the hybrid system ? or as you put it, the house that you built ? was turned upside down. Tell us about what happened? Dr . Rogu : The way I look at the industry changes for technology companies (i.e., EHRs), in general, is just like the private practice industry. You have the small, solo private practice that cannot keep up with all the transitions, and the regulations, and all the new things and then they get taken over by a big hospital system. This is what happened with our EHR company. Our EHR vendor was a small private shop that made a reliable product. However, it got bought by Athena, a prominent EHR company.

Br an don : Was it the interface, the functionality, or something else you didn?t like? Dr . Rogu : Doctors should be able to open the application and have it work. They should not have to figure it out. I'm pretty good at figuring stuff out, and I couldn't even start. I couldn't find the beginning. That was the reason we didn?t like it. It wasn't intuitive enough. Br an don : Do you think the difficulty you experienced navigating the application had to with your practice?s culture and being accustomed to the old EHR, or was it inherent in the design of the system?

Br an don : In the interview with Susanne, you specifically addressed how a change in your technology would cause significant disruption, not only to the practice and the employees but patient care would suffer as well. Tell me about what went through your mind. How did you approach this significant disruption?

Dr . Rogu : No, no. It's the culture of EHR companies in general. You see this in the hospital. Everything is made for internal medicine. Also, they think that pediatrics is just like treating a little adult, so they try to squeeze pediatrics into a template that's built for adult medicine. Athena is for adult medicine. It doesn't work for pediatrics. However, that is what a lot of these prominent vendors do. They say, "Okay, it's just an HPI. It's just a patient history. We'll throw in some ear infections and some strep throat templates and make it pediatrics.? That's not it. PCC and OP just do pediatrics. There's a difference between a hospital that has a pediatrics department and a dedicated children's hospital ? OP and PCC are like a children's hospital.

Dr . Rogu : Moving to Athena meant we had to outsource billing entirely because Athena doesn't sell you an EHR. They sell you a billing service, and they let you borrow their EHR. So, we did not want to do that. I knew of an EHR that interfaced with our practice management system. Since I was the hybrid guy, I said, okay, we're just going to replace the EHR and connect it with the practice management system. It shouldn't be that big of a deal. The change will only disrupt the doctors and not the staff. I was confident that was the way we were going to go.

Br an don : You mentioned PCC and OP. Tell me about your experience with these two pediatric-centric EHR/PM systems.

Br an don : You planned to take this other EHR (not Athena, but another vendor) and attach it to the practice management system which would allow you exchange a piece of the puzzle as opposed to replacing everything?

Dr . Rogu : I needed to develop a clinically integrated network (CIN) out in Long Island, which we did. That meant I needed a system that was able to be connected with regional extension centers. I also needed a product that had a large footprint in our area, and Office Practicum did. On Long Island, there was only one practice

Dr . Rogu : Correct, but that didn't happen. Br an don : Sounds like it was a great idea. Why were you not able to make that happen? 38

ehr transition that used PCC?s EHR. Half of our clinically integrated system practices have Office Practicum; which simplified the data aggregation process that is critical to the CIN.

Dr . Rogu : It has to be suitable for the staff and the physicians, because, if whatever you do in the system puts a roadblock for the team, eventually that roadblock is going to block the physicians as well. It's going to slow things down, so it has to be moldable, adaptable, changeable, and easy to use.

Brandon B: EHR companies like OP and PCC have an excellent reputation. They are also pediatric-centric which makes them appealing to the pediatric community, naturally. However, they are small companies when you compare them to a company like Epic, for example.

Br an don : I want to go back to when you found out about the impending transition. What was the reaction of your physicians and staff when you told them the news?

Dr . Rogu : We also looked at Epic. As you know, there are subsidies opportunities from hospitals. Choosing Epic would probably have been cheaper upfront, but you know what? That was going to be another problem in the future.

Dr . Rogu : Well, at first they were shocked. They couldn't believe it. Then they were depressed. Then they accepted it, and they moved on. It was like the grieving process, you know.

Br an don : What do you mean? Br an don : When making significant transitions, experts recommend designating a cheerleader, a project champion so to speak. Did you have someone in that role and if so, what was their approach to get everyone on board?

Dr . Rogu : It can be a problem down the road because the hospitals subsidize the software for just a few years. Those funds reduce the upfront cost, but after several years, you're on your own, and the ticket on that was astronomical. Br an don : What you are saying is, just because there's some initial financial incentive, it doesn?t mean it is a good long term strategy.

Dr . Rogu : I guess you can say I assumed that role. I tried to be the physician leader in the organization, and every day I?d send out a message to encourage the physicians and staff: "We're doing great!?

Dr . Rogu : If you want to stay in private practice, you have to invest money into your private practice. If you don't have money to put into your practice and you're going to have to be subsidized, then you shouldn't be in private practice, you know? Simple as that.

Br an don : So, not only were you the designated project champion and informing staff about what is going to happen, but you also embraced a leadership role to keep motivation and morale high, because you knew it was going to be a difficult transition.

Br an don : Any other long term considerations physicians ought to consider when looking at Epic?

Dr . Rogu : Correct. RBK [Pediatrics] was like the Titanic. We were going to hit an iceberg. So we did everything in our power to steer away from that iceberg. All those positive messages and words of encouragement helped people get through the transition.

Dr . Rogu : I think many people get trapped with these types of deals. For example, they sign up for a subsidy from a hospital to use Epic. The practice data goes into the hospital?s database platform, and as time goes on, the practice is stuck because they can't pull out the data. And then they have no other option but to sell out to the hospitals.

Br an don : In my experience, one of the biggest challenges with software transitions in particular is dealing with and managing generational gaps. Did you have issues? Dr . Rogu : Most of the younger generation, they had no problems. The mid-career people, found it a bit more challenging, but eventually they came through it.

Br an don : If the cost of the EHR should not be the priority, then what should be important when considering an EHR? Dr . Rogu : You have to pick software solutions that are good for your specialty; that is simple and intuitive. You also have to touch it; you have to look at it. You can't just make a decision based on what somebody else said. They could be wrong. They're giving you bias, their bias. The software has to feel good.

Br an don : What would you say was the breakthrough? Dr . Rogu : As long as you believed in it, it worked. If you were one of those naysayers, those negative Nancy kind of people, nothing that you say would work. I had to try to change the culture into a positive culture, not, "Oh my God, what are they doing to us? What are we going to do?" That doesn't help anybody. It just makes for a negative culture, and you're not going to succeed.

Br an don : What about the clinical staff? Does it have to feel good for them too or only the physicians?opinions matter?

Br an don : You mentioned negative Nancy. I want to 39

explore that a bit. Did you have a complete buy-in, or was there some resistance?

an all-inclusive software solution (i.e., EHR, PM, Patient Portal)?

Dr . Rogu : The interesting thing is that we had complete buy-in from the clinical staff. The leadership, the physicians, that was difficult.

Dr . Rogu : If I were to start from paper charts today, I would do an all-inclusive cloud model. It's much easier ? no servers in the office, no security risks and things like that.

Br an don : Why do you think the partners and physicians had issues with the transition?

Br an don : So you've changed your mind. That's undoubtedly a big pivot from two years ago.

Dr . Rogu : I think what happened with them is they got numb to the whole thing because they couldn't do anything about it. It's like learned helplessness, so they didn't do anything.

Dr . Rogu : Yes. But again, if your operations are working, don't change it. Change it only when something makes you change. Just ride it out as long as you can ride it out. I think in five years, technology is going to be even easier, so maybe in five years, change will be more straightforward. Who knows?

Br an don : How did you handle it? Dr . Rogu : Those guys needed a lot of hand-holding and encouragement, ?Come on! You can do it! It's going to be fine. It's just another EHR. It's not that big of a deal. It's easier to transition from an EHR to an EHR than it was from paper to EHR."

Br an don : Is there anything else you?d like to add as a final thought? Dr . Rogu : Yes, I do. The old EHR was good for the time. Doctors were able to write their exam notes, push it to the billing, and the bills went out. Everything was hunky dory, the work plans, the ordering of vaccines, everything. What they didn't do well, and I think this was their downfall, is that they did not prepare for the future, which is the population health side.

Once I got through to them, then it was a little bit easier. If the leadership is not positive about the project and they shut down, then there's a trickle-down effect to the nursing staff, to the secretarial staff, to the administrative staff. So, getting the partners and physicians on board was key.

EHRs contain so much data, but if you can't pull it out, it's useless to you. It's a glorified typewriter. That's what I like about our EHR, it's like one monster spreadsheet. Every little box, every small cell, means something. You can then extract the data, and you can share it with all these different entities.

Br an don : You mentioned earlier that the younger generation adapted quickly. Did you rely on some of the younger physicians that embraced the new transition to help you with moving others along? Dr . Rogu : I did have some help from the younger staff. I divvied out jobs and projects to different people in the organization. "You're going to be in charge of this piece. You're going to be in charge of templates. You're going to be in charge of medications." I also had to report to Office Practicum on what we completed.

For example, our clinical dashboard took our Excel spreadsheets and put them into pretty charts, and merged it with other EHRs. Unfortunately they did not continue to develop; whereas PCC and Office Practicum, they do develop, and they move on for the future, and they're adjusting. That's why they're still around.

Br an don : It sounds like you had a robust project management system with deliverables and task assignments. Was this vendor driven, or was this a practice driven initiative?

Br an don : You mentioned earlier that small vendors are vulnerable to more prominent companies. One could argue that Office Practicum and PCC are relatively small when you compare them to Epic or Athena, but what you're suggesting is that companies like OP and PCC continuing to push, think about the future, and adapt to the changes.

Dr . Rogu : It started as a vendor-led initiative. They provided spreadsheets with tasks that had to be accomplished by X date. That gave me the homework list that I had to assign to the team. I guess the vendors were better at figuring this out. We just realized how to implement what they already thought up at the practice level.

Dr . Rogu : I believe so. You know, I look at it this way; They're big enough to matter in the marketplace, but they're small enough to be able to change.

Br an don : What you have now is virtually the opposite of what you had before. What are your thoughts on having

isoutsourcingyour onl ine presencethebest option? Dr. Dan Feiten, MD Remedy Connect

Your website and social media are your primary outreach to your patients and all prospective patients. More than 90% of new families check out your website and your online reviews before they decide to contact your practice. Hence, your ?digital platform? (website, social media, reviews, and lead generation) should be looked at as an investment rather than an expense. With time, you should be able to use this platform to understand what the return on your investment (ROI) will be. Your decision to outsource your digital platform will depend on the resources that you may or may not have in the following areas: Money, Time, and Marketing Expertise.

onl inepresence M ONEY

media posts usually fall under a lower priority. Consequently, tasks related to online presence and management often don?t get done in a timely manner. However, partnering with a digital marketing firm makes your online presence into a priority.

If your practice is growing at an acceptable rate, you have few competitors in your area, and you have limited funds, consider starting with an easy ?Drag and Drop? website service such as Wix or Squarespace.

M ARKETING EXPERTISE

If you are a new practice, you have a dilemma. You need to be found, but you are also trying to conserve cash.

Gone are the days when you could put up a website and be found on the internet. Digital marketing for healthcare has become more complex. And if you want to grow your practice, this may be the resource you lack the most. Below are just a few reasons you may want to consider outsourcing your practice?s website and online presence.

Google algorithms make it very difficult to rise to the top of the search results without search engine optimization, social media outreach, and online reputation management. However, creating and implementing a consistent, positive digital trail takes time, money and marketing expertise.

Com plexit y ? Google uses over 200 criteria in their ever-changing algorithm to determine if your site should be placed on the first page. Every day, Google and other search engines gather billions of pieces of data. They can find out who, when, how and where someone visited your site. With other applications, they can tell you the age range, interests of your visitor, and they can track everything that a visitor did on your website. Trained healthcare marketers know how to use this data to attract more patients for you.

TIP: Just as you negotiate bank loans and lease or finance your equipment when you?re starting out, consider using this approach when negotiating your website development. Ask your web and digital marketing firm to let you pay a monthly fee for local ?findability? (i.e., digital marketing) services in exchange for a lower upfront fee to build your website and social media platform. You will be getting the digital marketing clout that you need in your early stages and paying less up front.

TIM E

Ch an ge ? Digital Marketing/Web Development companies must keep pace with the multiple changes that occur on search engines and social media platforms. It is difficult for the average practice to track this on their own.

The cost of your digital platform is not just related to money. It can also be the cost of your time away from the business, the practice, or family. How much time are you willing to put into developing a website? Can you afford the time needed to bring your digital platform in-house? Do you have the time to send bi-weekly posts?

Expan din g levels of exper t ise ? Colleges now offer degrees in digital marketing, SEO and web development. Other medical practices, hospital groups or urgent care centers in your area may be using their expertise to increase their online visibility while pushing your practice down Google rankings or search results.

Outsourcing your digital marketing affords you to do what you do best, focus on your patients. Outsourcing also allows you to focus on your practice. Concentrate on training your staff on how to provide excellent service rather than teaching them on how to do SEO (search engine optimization). An added benefit is mitigating staff turnover. The staff member in charge of managing your Facebook account can quit and be gone the next day potentially wasting months of training.

Review s ? Practices that want to grow must monitor and proactively increase their online reviews (i.e., Google, Yelp, Facebook). Online marketing experts have the tools to significantly increase a practice?s online reviews in an ethical manner. For some practices, they can see 100 reviews in less than 6-months.

Practices generally give priority to the needs of the patient(s) first, and practice management issues like billing and coding, collections, staff issues, second. Understandably, the website, online marketing, and social

Social M edia - Your social media & website should complement one another. You can use social media to be the prevalent source for pediatric information in your community, post regularly to Facebook, Twitter,

onl inepresence and Instagram, and create campaigns to engage patients or bring awareness of a topic. However, maintaining these efforts takes time. Google M y Bu sin ess - GMB is essentially your practice?s Internet profile. Managing the practice?s GMB profiles gives practice owners control over what shows in the search results when someone searches the practice?s name (i.e., office location, office hours, access to public transportation). Moreover, it integrates your profile with Google Maps and your Google Reviews. Although not a social media platform, GMB should be part of your practice's social media marketing strategy. Pediat r ic Con t en t - Providing great pediatric content will help parents in their research process and establish you as an expert in your field. Content is ?king? and a great way to engage with patients on your website. When you post content to Facebook or other social media profiles, you should redirect your patients back to your website for further information. M issed Oppor t u n it ies - By outsourcing digital marketing services to a web development company, you can gain leads and track data to understand some of the ways that you have been missing patients who wanted to join your practice. When looking for a company that provides website and digital marketing services, look for one that wants to be your partner rather than your vendor. To help you determine the difference, consider these simple, yet effective questions: Are there people who you can talk to if you have a concern, issue or need to make a change? Who can you call when you have a problem or need clarification? What is the representative?s name? How quick is their response time? Outsourcing your digital marketing platform is a complex issue and you must consider your budget, time, and marketing expertise while bearing in mind the competitive nature of your locale. This process is an investment in the growth of your practice.

Dr. Dan Feiten is the co-founder of Greenwood Pediatrics in Denver, CO and a founder of RemedyConnect. RemedyConnect is the combination of two influential companies who have been at the forefront of new technology for the past decade. Pediatric Web is the largest pediatric web design and development company in the country. MedSecure's proprietary software became the first digital answering service, allowing physicians to save money and avoid mistakes by bypassing the live agent.

pointsof view: recommendedreading From the team at The Verden Group

howtocreatethebest teamfor your practice "Behind every successful pediatric practice is a group of people who bring a unique set of skills and strengths to their work. From front desk staff and billers to nurses and pediatricians themselves, patients rely on this team when they visit your practice for an appointment. They expect staff members to communicate effectively and the team to function smoothly. Hiring the right people is key to realizing this positive experience for your patients. How do you find employees who will thrive? How do you build a team that meets the unique needs of your practice? How do you know if your partnership is working?" To continue reading the article click here: w w w.blog.pcc.com

howpracticescankeeppatientsintheageof consumerism Fr om M edical Econ om ics "As patients are demanding more convenience in our current era of consumerism, practices need to cater to consumer behaviors in medicine in order to stand out from competitors. Here's some advice on how to maintain patients and accommodate their needs. "Some rural doctors might get patients not because they are amazing doctors, but because there aren?t many options. But the day a competitor moves into town with a higher level of care access and communication, they?ll be out of business. They need to take the time to up their game." - Susanne Madden, The Verden Group" To continue reading the article click here: w w w.m edicalecon om ics.com

trendsinprovider consol idation Fr om Th e Healt h car e Econ om ist "A policy paper by the HHS describing proposals to promote choice and competition in health care. Before getting into policy recommendations, however, it outlines how increased provider consolidation has lead to less choice. large hospital groups have been buying medical practices and more MDs are working for large hospital groups than ever before. Market concentration, however, not only varies across geography but also by physician specialty." To continue reading the article click here: www.heal t hcare-economist .com

48 www.verdenviewpoint.com