PCC’s theme for the conference was “Change” so I decided to title the talk 101 ways to transform your practice and expand the post I was working on into an hour talk. But I also wanted to do something different with my slides.

When I go to conferences, I usually ignore people’s slides. Why? Because most people use their slides as a teleprompter. Second, I usually can’t read and listen at the same time so I prefer to listen (surprisingly, I can text, read and respond to email while listening although my wife doesn’t agree).

I also ignore slides because they add little value 3 or 4 weeks after the presentation. Most of them are full of bullet points with half sentences and they usually don’t have examples. Three weeks later I’m trying to remember what was that funny analogy the presenter made about handling Medicaid patients so you don’t lose your shirt but the slide only says:

• Manage Medicaid patients better.

I decided to create a workbook that would expand my hour talk with more insight and depth. I also wanted to be able to have attendees have something to take with them that was comprehensible 3-weeks or even 12-months after my talk.

I created my slides and I also created a workbook that went a little more in depth and provided some context to my talk that we distributed to the attendees.

After the talk, I decided to make the workbook into an e-book and put the e-book up on the blog for giggles. I knew the e-book wasn’t perfect. There were grammatical errors, several typos and a few formatting issues. But I ran with it. I told myself, if I waited for it to be perfect, I would never put it up.

Besides, any edit job would take a while considering I wrote 101 different things. It was good enough I thought.

As it turned out, a lot of people wanted the e-book. More than I expected. Which is a great of course. But the typos, grammar and formatting bothered me the more people requested it. I decided to have the e-book edited by a professional and adjust a few formatting issues. It is now up to standards!

So, to make a long story a little longer, I’m happy to let readers know that I have an improved, updated version of the e-book.

If you want the improved edited version, I’d be happy to send you the updated one. Even if you already have one. Just send me a note by going here.

Here is the catch though.

You have to share it with at least one person. No, I’m not asking you to start a chain letter. Just share it with other doctors and practice managers that you know.

And the second request I have is for you to consider signing up to receive updates every time I post a new post on the site. If you are not a subscriber, then visit the email subscription section of the blog.

Hope you enjoy it.

Now it all makes sense.

Enjoy!

The real benefit of an EMR isn’t being able to put data in/chart faster – this is great if you can do it but not everyone can point/click/type faster than they can check boxes–

…the real benefit of an EMR is getting practice-wide data quickly OUT of it.

When docs test drive EMRs, they want to see “How do I put in the vitals?  How do I issue an Rx?”  As far as getting data out, they want to see patient-specific, single-patient data: “Show me the kid’s growth chart.”  “Show me their pattern of no-shows.”

But the real ROI is learning how to get data OUT – report writing and so on.  Most docs never learn this, or expect the administrator to do it all.

I’ve posted on SOAPM before about how we found $3K/month in lost revenue in labs we weren’t billing for by cross-checking the number of, say, strep tests documented in the chart vs 87880’s billed for – at a cost of $100/month.   Is $3K/month a huge cash cow? Nope, but it’s something we wouldn’t have had otherwise.

We get another perhaps $1000/month for running reminders on missed E&M, 99050, etc.  and we already run a pretty tight ship.  Other practices have found similar results from cross-checking vaccines, etc.

By reporting on how many different days I saw kids at our local hospital (place of service 21 or 22) I can give our practice’s accountant a nice list of work-related mileage from our office to the hospital.  This is maybe $500/yr in tax savings for me and my husband.  Is this ginormous? Nope, but since the report is already there and it takes 2 minutes to run and print, $500 earned in 2 minutes work is pretty good.

Having the computer do the various annual reports that are required of the various programs we participate in saves my nurse administrator time.  How many VFC vaccines from a certain lot did we give between date A and date B to self-pay vs. Medicaid patients? How many H1N1 vaccines did we give during a period?  Point, click, print, fax, move on.  No hand tabulating.  No adding up long columns of numbers by hand.

There’s a new Framitz machine that’s now CLIA-waived!  It’s on sale, $5000, and the cost per test is $3.  Insurance reimbursement is $8.   Is it worth it? Depends on how many Framitz tests we sent out last year — and with a couple clicks, I can see what the ROI on a new Framitz machine would be.

I don’ t expect everyone to be the data mining geek that I am – but I posit that you will never reap the rewards of an EMR if you don’t know how to get practice-wide data intelligently OUT of it.

And that’s the trouble with spending a lot of time on scanning old data into the EMR – it’s clunky and time consuming, and you have to do it, but the data you’re putting in can’t be extracted in any meaningful way (unless you are doing some really awesome indexing) to do the cool things I’m talking about.

I have done the contract negotiations for my practice for 20+ years. In those dark ages, before Internet and AAP resources, there was no primer for doing this. One of my partners recently asked how she could get up to speed on this, looking to the point where I might retire – which is not anytime soon. So I started thinking about a few essential points to have in contracts. You may not be able to get all of them, but they are all worth fighting for.

1. Do a payer analysis so you know ahead of time what % of your practice income comes from each payer and what each payer is paying you for the major E/M codes. This means learn spreadsheet 101 software. Sometimes you need to be prepared to tell a company their offer is not acceptable and walk away. You need to know ahead of time what this may cost you. You also need to know whether you are the only pediatrician for 30 miles or whether there are 3 other practices within 5 miles who would be happy to snap up your cast offs.
2. Become familiar with RVU valuations. AAP book Coding for Pediatrics issued yearly is an excellent resource for this.
3. Ask for fee schedules based on a percentage of a given years Medicare, rather than just “we will pay you $x for code y. If you are lucky enough to get them to agree to basing the fee schedule on the current year, be aware that Congress is still playing with something called the SGR, which, if not fixed, may cut payments from Medicare by 30%. Fee schedules based on prior years Medicare are fixed in stone at this point.
4. Know your area. There are parts of the country where simply getting 100% of Medicare is considered good. There are other parts of the country with rates as high as double that.
5. Try to get a concession that they will follow CPT coding guidelines. I have been unable to get this in any contracts. But by bringing it up, it opens the door to specific discussions of paying for –25 modifiers for well and sick care on the same day, and bringing up what services are or are not bundled into well care, such as vision, hearing and developmental evaluations and after hours care.
6. If in office lab is a big part of what you do, insure that what you are paid doesn’t lose money. You can always threaten to send every kid who needs a specific test to the hospital if they don’t at least meet your cost.
7. VACCINES: know you costs, know your overhead and make sure that you are paid appropriately. These are almost always carved out of every contract and can cost you tons of money. Inscos often try to pay less than your acquisition cost for vaccines. Try to get payment based on the CDC price list. http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm. Also check out the AAP information on the Business Case for Vaccine pricing. This one piece of the contract can make or break you.
8. Try to avoid forever renewing contracts. A good price today is going to look pretty poor in 5 years when it hasn’t changed. 2 years is a reasonable amount of time so you are not forever negotiating.
9. It takes 6 months to negotiate a contract and they are almost always completed after the actual termination date. Stall is the name of the game for inscos.
10. When you agree on a contract, make sure the contract they send you to sign is actually the one you agreed to. All the companies have boiler plate contracts. I have had a company agree to give me specific terms, but the contract sent to me was 3 or 4 drafts prior to what we agreed upon. I was told this was an “oversight”.
11. Once you agree on the big things, like payment for E/M codes, don’t forget the little things. Will they pay for after hours care and in office labs are the main things here. If they don’t pay for a specific service, do they consider it “bundled” which means you can not charge the patient, or do they consider it “not covered” which means you can bill the patient.
12. Not that I don’t trust people, but once you sign a contract, look at the EOBs that come in and make sure that they are really paying you what they said they would pay you. You’d be surprised how often the insco computers load the “wrong” fee schedule by “accident”.
13. You may not win even if you think you won. A comeback offer from an insco may take the form, “We will give you 10% more on E/M codes, but pay you 5% less on vaccines.” You have to be able to know that this 2nd offer may actually pay you less than the first. It can only help you in negotiating when you come back to them with something to the effect of how disappointed you are that they think you are so naïve, so how about a real offer, not a trick offer. Know what they mean by “E/M codes”. In my experience, they mean only Office Visit and Preventive Care codes. And even though all the other common codes for hospital care, newborn care, in office counseling, etc. are in the E/M section of the CPT book, they usually are not included in the insco definition of E/M.
14. Know a ballpark minimum offer that you simply can not go below. If you don’t get it, WALK AWAY. This is the hardest thing to do. But if you are losing money on a payment schedule, you can’t make that up by doing more volume.
15. Start your 1st negotiation with a payer who is rather MINOR in your income. This way you can learn, get your feet wet, and mistakes (which I still make) are not so costly. Save the big payer negotiations for after you have gotten some experience.

This is a starting place. I’m sure others on this listserve will be happy to offer more critical points that I have over looked. And some of these items can be rather daunting. It can take a while to get proficient at Excel. If you have a spreadsheet wiz in the office, it might be reasonable to delegate this part of the task. And getting the Medicare fee payments for the common codes that you do may be somewhat hard if you are not good at Excel. The AAP and Chip Hart on this listserve have good sources of information about common CPT codes and their valuation.

My short answer is, go for it! My long answer is, well, more complicated.

First, I think it is important to assess one’s priorities and determine the true motivation for opening up the practice. Motivation – or the reason why – is very important because if one opens the clinic for the wrong reasons, failure is often the consequence.

Here is why… during the journey of opening one’s own medical practice, one will no doubt be challenged, get burned out and perhaps even question if this was the right thing to do or ask yourself if this is even worth it. If one’s motivation is fragile and things get tough, the likelihood one will preserver through it will be more difficult.

Thus, in our experience, the motivation has to be more than money, be your own boss or just to say you have your “own” practice.

So the question for me isn’t whether the conditions are right to open up a practice, but rather, do you have the right motivation to open up a practice in this environment. Because what one selects as the reason is what will give you the strength to forge ahead regardless of good or bad times.

Once you’ve settled that, then you can move on.

I jotted down these 12 points regarding opening up a practice. They aren’t really advice or tips per se, but more my thoughts. Here we go:

1.  First thing first… join SOAPM. What is SOAPM? Glad you asked. Go here and here to find out.
2. Location, location, location. Just like any other business, location is very important. Research the area. Figure out the type of “patient mix”, demographics, access and all those great things that make a great location. Tip: Census data can help you get started with this research.
3. Understand that working for yourself is going to be more stressful and more difficult than working for someone else. Why? Because the buck stops with you.
4. Although the work is more stressful and probably work more than you’ve ever worked in your life, the personal and professional rewards will be much greater than you’ve ever experienced (and potentially even greater financially).
5. Understand that the practice is a “business” just like anything else. What that means is that at the end of the day, more money has to come in than go out. Don’t forget that because you can’t help people in need if you are in need.
6. As soon as you can, hire a real business manager.
7. Be prepared to make sacrifices. For example, sacrifice time with your family.
8. I’d recommend finding “consultants” to help you get things in order. They will cost you money but it is a good investment. Also, find people to handle your hospital and insurance company credentialing process.
9. Try to find other “solo” physicians in the area that you can share the on call schedule with you. Otherwise be prepared to work 24/7 until you find another doc.
10. Although it is expensive, start the practice with a good EMR and a very good Practice Management software. Thanks to Obama, there is an opportunity to get financial help with this expense.
11. Join a physician buying group ASAP. This will help you offset one of the largest expenses in a pediatric office (i.e., vaccines). Group Purchasing Groups will also help you get discounts on other items.
12. Remember, if failure is not an option, either is success.

This list is not comprehensive. There are many, many more things to consider. But I figure it is enough to get you thinking about a few things before you begin the process.

The AAP also has some resources in this area: For example, Practice Management Consultant

For those that started a practice recently, what advice, tips or pearls of wisdom would you give someone that was starting today? 

In case you missed them, here are the top 10 post for 2011.

1. Is Your Front Desk a Command Center?
2. Top 11 Pediatric Facebook Pages
3. Patient Collection Letters, What is Your Approach?
4. Medical Practice Advertisement
5. Tip #3, How To Save $80,000
6. How Social Media Can Transform Your Medical Practice
7. Can Costco and Your Medical Practice Have Something in Common?
8. Does Your Medical Practice Have a Problem with Bad Debt? Here is a Solution
9. Ten Hidden Cost When Implementing an EMR
10. Seven Reasons Why Medical Practices Have Yet to Adopt EMRs

The list is ranked by total traffic. Funny what people find more interesting. Usually, my top 10 are not the same. Here are some of my favorites:

1. What Can A Practice Learn from Bon Jovi?
2. 10 Practice Management Reports You Haven’t Thought of
3. Can a Medical Practice Learn from an Airline?
4. Small or Big: What is the Future of Small Private Practices
5. How Do You Approach No Shows?

Did you have any favorites you’d like to share with us? Which one did you find the most helpful? Leave a comment down below. I’d love to hear from you.

Have you seen those signs in doctor’s offices that read, “The best compliment you can give us is a referral?” Some say this is a great way to get referrals. Simply asking for one.

I’ve also heard “healthcare marketing professionals” suggest that doctors ought to spend time in the community networking with other physicians like OB/GYNs, neighboring schools, daycares or any other person that can send a patient our way.

At Salud Pediatrics, we’ve done all kinds of things… for example, we’ve sent out letters to OBs, we’ve stopped by to say hello at daycares and also dropped off a few business cards at the local pharmacy.

But I wonder… are all these suggestions the right approach? Is doing all those things the best way to get referrals?

Let’s think about this… why would someone agree to refer a patient to you or to your practice? What is so special about your office? Is your Prevnar better than the other doctor’s Prevnar? Is your Amoxicillin more powerful than the one that is prescribed at the local retail clinic? Are patients going to refer to your doc because he wears a Mickey Mouse bow tie or because your waiting room is decorated with trains?

Those are all nice things, I suppose; but are they enough to help people decide whether or not to refer patients?

Think about some of the places, restaurants, vacation destinations or other professionals you’d be happy to refer your family, friends and acquaintances. What was special about them?

Let’s take your favorite restaurant as an example. What is it about that place that that makes you want to tell others about it and to encourage them to go?

Is it the way the servers dress? Is it the decoration? If it is food? Is it the peanuts shells on the floor? Is it the friendliness of the staff? Is it the size of their huge beer jug? Is it because it is cheap and good or because it is expensive and fancy?

My guess is that it could be one thing our all of those things. Who knows. But the constant is always the same; which is, the place is remarkable in some way. Otherwise, you wouldn’t bother referring anybody. Right?

Therefore, the real secret to getting the most referrals…. ready?

…you have to be remarkable is some way.

Thus, our focus should not be on getting the word out so much (although getting the word out is important), but rather working on being worth remarking about.

One last thing… most doctors that I know will say that their quality of care is better, thus that is what sets them apart. Perhaps.

But we know that statistically speaking, every single doctor’s quality of care can’t be superior. I mean, if everybody is super, then nobody is.

So if your quality of care sets you apart, then it ought to set you apart. It has to be evident, obvious, and noticeable. Otherwise, unless that person is your friend, why would anybody else refer to someone that is, at best, average?

Godin says, “the only thing that will make you remarkable is being worth remarking about.”

So here is the challenge. Take a look at every aspect of your practice. Everything from the way you provide care (if you’re the doc) to how the practice answers the phone to how letters get sent out in the mail and see what is remarkable and what is not. Separate the average from the worth remarking about.

Then, all you need to do, is get to work.

But very few actually take the time to ensure that their most valuable assets have what they need to perform their best. We believe they have what they need; we think they are comfortable; we assume they are happy, but how do we really know?

We have a small group in our office that has been with us for a long time and for the most part, I have always assumed I have a good understanding of how they feel about their jobs, their coworkers and the company in general.

But then I realized, I’ve always assumed. Never have I asked direct questions about  how they truly feel about me (as their leader, boss, or manager) or the medical practice.

So I decided to change that.

I drafted a series of questions to ask our employees. The questions were designed to  get a better understanding of their feelings about me as their manager, the office, their co-workers and the company in general. I also wanted to determine if our most valuable assets have what they need to continue being our most valuable assets.

And here is what I asked them to complete:

1. What is most satisfying thing about your job?
2. What is the least satisfying thing about your job?
3. Do you receive enough training to do your job effectively?
4. Do you receive adequate support to do your job?
5. Are you satisfied with this company’s merit review process?
6. Does this company help you to fulfill your career goals?
7. What can we do to make your position better?
8. If you could define our practice philosophy in one sentence, what would you say?
9. How does the management do at treating you and others employees as their first customers?
10. Has management been fair and consistent when dealings with employees? I not, explain why not.
11. What could management do better to express loyalty to the staff and to gain loyalty from the staff?
12. Do you feel you are adequately informed ahead of time about changes?
13. Do you feel in control of your workload?
14. Do you feel your bosses are open and honest in dealing with employees?
15. Do you have a clear understanding of what is expected of you?
16. Do you dread coming to work everyday? If so, why?
17. Is the office environment between employees and physicians comfortable?
18. Name 3 things your boss could do better to serve team members.

I asked the staff to answer the questions to the best of their abilities. I told them that the more they shared with us, the better. Not only will the responses give me an idea of areas where we can improve on, but it also is a way to gauge how satisfied they were with their job; which is crucial in helping us achieve our mission at the practice.

I could tell they were a little hesitant to fill it out the questionnaire. They wanted to know if it was anonymous and if their would be consequences if we didn’t like the answers.

I explained that it was not anonymous. Second, I told them that this was an opportunity to tell me what I could do better as their boss. And lastly, I told them that if they weren’t truthful, the exercise was worthless.

I did get very interesting responses. I’m still going over them, but some of the things that jumped out was how we/I reprimanded the staff. They don’t appreciate it when one of them screws up and all of them get reprimanded.

I’ll have to reassess this issues as it conflicts with my all for one, one for all management philosophy (if one fails, we all fail; if one succeeds, we all succeed).

They also pointed out that we/I did not do a good job of letting the staff know of changes within a reasonable time frame. So now, I know to announce things sooner rather than later.

I still need to go over them in detail, but overall, the feedback went well I think. I learned there are areas I need to work on and I also got to know my staff a little better.

Do you think this is a valuable exercise you could do in your practice?

How long before your practice runs out of money? 

A month; a day; 3 months?

This is a very important question to answer. Why? Because it helps us have a perspective on the business and when and how to start making decisions.

In the How The Mighty Fall: And Why Some Companies Never Give In Jim Collins talks about how companies start to fall apart way before they actually fall apart. Like a disease that starts to affect the body before symptoms are visible, many companies start the decline before the leadership even is able to make a diagnosis. And often times, by the time the leadership realizes there is a problem, it is often too late.

Imagine not having a gauge in your car that tells you how much gas you have left. How will you know when to stop for gas? I guess you could make it habit to put gas in your car every couple of days. But that isn’t very efficient.

Like the gasoline gauge in your car, knowing how long your practice can go before it runs out of money will help one prepare way before it is too late.

Take a moment and figure out how long you could make it if you ran out of patients today. Then, you can decide whether or not you need to increase your line of credit or start an emergency fund.

But more important, the exercise will be like a gasoline gauge in your car. It will give the leadership of the practice a visual display of sorts to assess the current condition of the practice.

Knowing this information also helps you and your practice get in gear. In other words, when you see the reserves drop, you can go into reverse course mode and start going down a path towards recovery (e.g recalls come to mind, delaying large expenses or cutting back on expenses) before it is too late.

Because the AMA doesn’t let anyone provide a free RVU calculator that includes CPT codes due to their CPT copyrights (booo, booo), the great folks at Pedsource (yaaay, yaaay) created this tool for those of us who have a CPT license that allows for a use such as this. In theory, that should mean any practice that submits insurance claims.

What is this tool good for?

The tool allows you to choose your CMS-driven location, set a Medicare Multiplier, and then, on a code-by-code basis, determine your pricing level. Basically, you can use this spreadsheet with the data that you can download from CMS to make a fairly sophisticated RVU calculator in about 5 minutes.

One can then include your practice’s own common codes, volume and pricing, and the spreadsheet will determine your practice’s FACF (i.e., how much you charge, on average, relative to Medicare).

You can also put in your practice’s payment information and the sheet will compare it to the Medicare fee schedule.

How does it work?

1. Download the OpenOffice version or the MS Excel version of the RVU calculator.
2. Visit the CMS site and download the 2012 RVU zip file. You have to agree to the license and usage rules from CMS first before they let you get to the data. The link above points to version A in 2012; CMS usually releases a few revisions through the year, but they usually don’t affect pediatrics and primary care.
3. Extract the PPRRVU12.xlsx file from the zip file.
4. Cut and paste the entire page of data from the PPRRVU12.xlsx file into the tab marked “PPRRVU12″ in the RVU Calculator spreadsheet (the one you downloaded in step 1). It is a big file, so be patience.
5. Choose your locality with the pull down menu.
6. Pick a Medicare Multiplier.
7. Then, enter your top CPT codes in column A.
8. Put some unit volumes (how many times your practice performed the code), prices, and payments in and watch what happens. Any field marked in a light blue-gray is a place where you can enter info.

I want to thank Chip Hart from PCC for creating this gem and for letting me share it with you all. Talk about sharing the love.