To market, to market! A marketing plan for the next 6 months.

 

cupcake1

As promised, I would set up a goal for the year, and plan to achieve it.  I had earlier noted that business for my company, ExtraMD was down for the first time in five years.  My company supplies physicians to clinics/hospitals/urgent care in the city where I live.  I am the physician owner, and feel responsible to the other 5 physicians in our group.  So, I developed a marketing plan for the next six months to bolster our shifts.  The general marketing theme was a birthday celebration, as ExtraMD is turning five.   

The goal: have 5o shifts per month for our physicians.   (This is what we usually have, but has suddenly decreased.)

Unless noted, all responsibilities for marketing are mine.

The plan (by month):

January: send an email to our clients, announcing our birthday celebration, and giving a discount of 10% off the first shift.  (Already done by our trusty office manager.)  Send out a press release announcing the birthday celebration.  (My responsibility.)

February: deliver birthday cupcakes to potential clinics with cards/brochures. 

March: build a referral tree via email.  E.g.: if a client refers someone to us that uses us to fill shifts, the referring client will get a discount off their next shift with ExtraMD.

April:  send out postcards reminding clients/potential clients of our services, focusing on how we benefit the practice when one of our doctors fills in.

May: send out email reminder for practices to book now for summer vacations.

June:  send out a newsletter with tips on practice management to our email subscribers.

Most of the marketing will be low cost.  This marketing plan was developed with help from Philippa Kennealy, a physician entrepreneur.  I also consulted Duct Tape Marketing, by John Jantsch.   I’ll keep you informed as to our progress.

Medicine Means You Never Have to Say You’re Sorry

Just as hospitals are encouraging us to apologize for our mistakes, comes a warning from Steven I. Kern, JD.  He cautions that admitting errors may result in loss of malpractice coverage.  He states :

For example, many malpractice insurance policies include a clause that allows the carrier to deny coverage if you do anything that adversely affects its ability to provide a defense.

He relates that saying sorry is basically an admission of wrong doing, and that anyone who hears you say that you are sorry can be used as a witness to testify against you in a malpractice suit.  Mr. Kern also notes that the push by hospitals for physicians to admit to mistakes may actually be based on an effort by the hospital to shift liability away from the hospital and toward the physician.  Yikes!  He also notes that saying sorry can lead to sanctions from peers, family wrath and economic loss.   What he recommends is that first, notify your “health care” attorney, and then together decide if you should notify your insurance carrier.  He then states that the three of you decide if it is appropriate to say “sorry.”  After that, the three of you will craft an appropriate response “to best communicate your regret in a way that is likely to make matters better, not worse.”

Mr. Kerns advice is good, but sad.  How pathetic that we live in a society where admitting we are human and that we have made a mistake is fraught with danger.   He does note that 35 states have variations on ‘apology laws’,  which he describes as “exempting expressions of sympathy and empathy to exempting admissions of fault.”  However, I still would check with your malpractice carrier first before making a move.

As he notes:

Unlike in church, confession doesn’t necessarily lead to absolution in the world of medicine.

I don’t know about you, but last time I checked, I was only human.  Crazy place, this world.

AHIP Rides in to Save Health Care

America’s Health Insurance Plans (AHIP) has released a plan on how to reduce health care costs.  The platform is summarized below:

The new reform proposal would:

Ensure universal coverage by guaranteeing coverage for pre-existing conditions, fixing the health care safety net, giving tax credits to working families and enacting an individual coverage requirement;
Call on the nation to set a goal of reducing the growth in health care costs by 30 percent;
Enhance portability for people changing or in between jobs;
Provide more affordable health care options for small businesses; and
Increase value and improve quality.

An admirable statement indeed. But once again, one must look a little deeper. 

Reducing costs: AHIP points out “Respected studies have shown that patients do not consistently receive high-quality health care and receive care based on best practices only 55 percent of the time.”  Hmm, does  mean that we as physicians are giving ‘low qulaity’ care the other 45% of the time? Who is determining what is ‘high quality’ care?  They advocate using “evidence based standards.”  Aren’t we already doing this?  Furthermore, evidence based standards typically apply to ONE disease state, not the multiple chronic problems primary care physicians deal with.  C’mon give us something fresh!  Stop blaming the doctors for the problem.

AHIP also advocates “exploring” replacing medical liability with dispute resolution. No argument here!  Now who will reign in the powerful legal special interest groups that so effectively court congress?

The reform proposal also advocate controlling fraud.  Now really, how big of a problem is this?

AHIP also advocates pay for performance.  This is a little scary, given the current P4P mess.  I could see this as just another way to with hold payment to providers.  Based on my work as a hospitalist, I find it laughable when the 80 year old post op knee patient is expected to be discharged on day 3.  However, insurance companies don’t care to notice the hypoxia, anemia and confusion attendant with operating on the elderly. Instead, they leave a bright orange sticker on the chart demanding that I justify why the patient is still in the hospital.  Good thing I’m not currently paid for my performance in getting the total knee replacement patient out on time.  The heck with hypoxia!  Clearly I must be doing something wrong and my pay should reflect this!

They also advocate “streamlining” administrative costs.  Gosh, I’d love to streamline my claims, and not have to have extra office staff there to beg insurance companies to pay the bills, or jump through hoops for pre-authorization.  Insurance companies should begin immediately to streamline their administrative costs–they don’t need a government mandate or huge reform to do this–but, I suspect, this may take money from their own pockets.

AHIP states another priority: “Refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions.”  This is something the health insurance companies should be doing already!  It should not take a “crises” in health care for health care plans to make STAYING healthy a mandate.  They also advocate strongly for “patient centered homes”, a concept that I think is just repackaging of the current model, albeit more top heavy with “midlevel”  and ancillary providers.  

Information technology is embraced (how fashionable!) but no attempt is made as to explain WHO will pay for technology.  Why don’t we admit that the emperor has no clothes?!  There is no money to pay for an EMR and nationalized technology.  Putting it on the backs of primary care practices will drive more physicians out of primary care.  Perhaps insurance companies should pony up for this cost?

They also advocate that everyone should have insurance, regardless of condition.  AHIP also states there should be tax benefits to small businesses so they can offer health insurance, and “large markets should be strengthened.”  They even suggest that the government offer assistance to small businesses. They also advocate broadening SCHIP and medicaid eligibility, as well as offering tax credits to lower income families.    This completely ignores the fact that medicaid reimburses so poorly  that  physicians can’t afford to see medicaid patients!  AHIP also wants  “community health centers” to receive “adequate” support.  Ah yes, another bail out in the making!

American Health Insurance Plans close with a mandate that the feds should provide a “framework” for reform, and that state governments should follow suit.  They also pledge to “cooperate” with the effort.  After reading the entire proprosal, I am left with just one question: what are the health insurance companies going to do?  Are they going to fly to Washington in their private jets to ask the government to pay for the uninsured?

 Visit the complete reform platform at:

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf

The Common Sense Declaration: How to Fix Health Care

I am on a reading frenzy, and finally got to the October 17, 2008 issue of Medical Economics.  There was an excellent article by Elizabeth A. Pector, MD, on fixing health care.  I will highlight some key points, but encourage all of you to see the entire article (pages 29-33.)  (www.memag.com)

“Establish equal rights for doctors.”  Dr. Pector advocates appropriate reimbursement, taming the paper tiger, and reigning in “etitlementiasisis” by patients.  Bravo!

“Improve access to doctors.”  She again targets physician reimbursement, but my only question is “how”?  Increasing physician reimbursement will be a tough sell in today’s economic times.  Sadly, I don’t see a way off the office visit treadmill that is the bane of primary care existence.

“Stop the blame game.”  Our society has turned into expert finger pointers.  Bad things just happen.  People die.  Sometimes, physicians make mistakes.  We need to have mutual respect between patients and physicians, rather than mutual antagonism.  And hey, tort reform wouldn’t be so bad either!

“Establish workable technology standards.”  Amen.  “We need to establish workable standards for PHR and EHR systems, including mutually compatible communications platforms.  Also, cash strapped doctors need help to fund changes…”  Technology is here to stay, but we need a coherent direction for all of health care, such that physicians and patients can access records through out the spectrum of medical institutions (clinics, offices, hospitals, nursing homes, etc.) 

“Stop punishing doctors and hospitals.”  See my previous rant on the medicare never ever no pay list.  The no pay list will continue to grow as Medicare pokes its fingers into patient management.  The no pay rules range from common sense to absurd, but there seems to be no one reigning in the free wheeling CMS.

“Take responsibility.”  Americans need to pony up and take responsibility for their choices, rather than shifting the responsibility elsewhere.  This will take giant social change, from throwing out the television and X-box to eating meals that don’t come in a “super size.”  Are we up for the challenge?

“Refocus the health insurance industry.”  Pector notes that physicians should be paid for what they do, with out the “gamesmanship” so common today when dealing with health insurance companies.  Additionally, she notes that insurance companies could actually (don’t faint!) assist in helping patients follow through on life style changes and medical compliance.

I think Dr. Pector is my twin sister of a different mother! Keep fighting the good fight, Dr. Pector!

10 Reasons Your Medical Practice is Failing, and How to Fix It

As the ExtraMD, PookieMD has seen lots of practices.  I have also been asked to evaluate failing practices to see where they got off track.  There are some common themes amongst failing practices.  For once, I will NOT carry on about reimbursement, but rather focus on where the physician owners of these failing practices went wrong. Here are my top ten reasons primary care practices fail:

  1. No budget.  With out fail, every time I have asked failing practices about a budget, I get a vague answer, along the lines of, “Well, we look at the numbers.”  NO!  A budget is not something your book keeper or office manager creates, and then places on a dusty shelf!  You need to look at it as a tool, and analyze where your practice’s money is going, where you want your practice to go, and why you are (or are not) getting there.  You must analyze variances and figure out why they are occurring.  When I say you, I mean YOU!  Yes, you must understand this process to guide your practice/business!
  2. Serious lack of planning.  We physicians are masters at trying to anticipate and forecast what happens with patients.  This same skill MUST be applied to cash flow.  You must forecast your cash flow  so you can plan ahead.  Good examples of bad planning: not anticipating paying your staff for holidays/vacations, not planning for the lost revenues while YOU are on vacation, not planning on HOW you will pay your new partner before s/he is generating enough to cover her salary. 
  3. Huge empty offices.  I worked at one office where one exam room was crammed with free give aways from drug reps.  You couldn’t even use the room.  Yup, pens, cute pedometers, plastic clip boards, heart shaped watches were stuffed into the exam room, rendering it unusable.  Yikes!  Who can afford that?
  4. Top heavy staff.  If you are a small office, you really need to examine how much staff you have, and how much your really use and need.
  5. Buying sprees.  Before you invest in what ever new gizmo you think will earn the big dollars, do a thorough market analysis and cash flow projection.  (Worst example I’ve seen: a gazillion dollar laser that a practice bought but never used!)  Don’t just believe what ever a vendor is telling you.
  6. Investing in an EMR and not using it.   I have worked for 4 different practices that bought EMRs and were too busy to a) use them at all b) wrote notes and then typed them in later, c) persistently scanned notes in.  I’m not kidding.  If you are going to get an EMR, commit!  Realize it will take oodles of time to make it useful, but for Pete’s sake, don’t buy it and have it sit there!
  7. Not putting in the hours.  All of the practices I have been asked to review had physicians that felt like they were working quite hard, but were only putting in 6 hours a day.  Many offices would open at 9:00 am, take a 1.5 hour lunch, and then the office would close at 4:30. 
  8. This is not your father’s practice.  Back in the day, the “GP” hung out his shingle, saw 10  patients a day, gave a shot of penicillin in the behind for everything and perscribed milk for ulcers.  If you think the business of medicine is that simple you are in the wrong profession.  Physicians must understand the complexities of today’s medical/legal/business world.
  9. Poor location/top heavy lease.  It’s tantalyzing to have the medical office suite with the fancy furniture and custom wall hangings etc., but get real.  See #1, BUDGET!
  10. No advisors.  We physicians are smart, but not smart enough to know everything.  The practices I have evaluated typically had physician owners that were trying to do everything themselves, with out utilizing advisor such as bookkeepers, accountants and business attorneys.  You must know enough to understand your advisors, but you also need to trust them to guide you.

If you see your practice here, get busy making changes!  Today’s climate is tough, so we need to get tough in how we run our practices businesses.

Survival Tips for Primary Care: How to Save Money

Now that I have vented/ranted/opined on the demise of primary care, let’s move to some survival tips. Following are PookieMD’s two fundamental. most important, and most loathsome rules of survival in primary care medicine.

The money is in the numbers.

Time is money.

Yes, you have to see patients to  make money, and given today’s reimbursement you have to see a fair amount of them.  This is a given, a fact, a law.  If you don’t want to see 20 (or more) patients a day, go in to psychiatry.  If you are in primary care, you probably are looking for a way to make a dollar go a bit further.  Don’t laugh, you might spot something useful here!

  1. Get a set back thermostat.  No, these aren’t just for home use.  If you are paying your utilities, why are you heating the office at night? 
  2. Learn to be efficient.  I have previously blogged on being efficient.  Running yourself ragged to see more patients is a recipe for burn out (if you are not already there!)  Look for ways to become more efficient.
  3. Use your EMR to the fullest.  For heaven’s sake, if you bought the thing, use it!  Learn every bell and whistle it has, every dot command, every work around, every reminder system. .  It will make you more efficient. Reminder: USE the perscribing feature (CMS will be rewarding this, and then penalizing you if you DON’T use it!
  4. If you don’t have an EMR use preprinted check box forms when possible. Write in the extras but the check box forms will save you time, and are usually more legible.
  5. Have your receptionist call and remind patients of their appointments.  An empty slot in your day doesn’t generate revenue.
  6. Look at how you use your space.  Could you rent a spare exam room to a occupational or physical therapist?
  7. Consider extended or weekend hours.  You are paying the rent whether you are open or not.  Consider opening a half day on Saturdays for urgent care appointments.  Don’t let Walmart take away YOUR business!
  8. Consider using medical assistants during their internship.  Lots of local MA schools are looking for practices that will take on a student.  These students are usually in the later part of their training and can extend your man power for free!  Beware, your nurse or MA should supervise them.
  9. Make sure you are billing for in-office procedures.  Train your staff to check off ua’s, strep tests, pregnancy tests etc.  You should then double check when you are filling out the superbill. You are doing ’em, get paid for ’em.
  10. Shop at big ware houses, like Costco.  Get toilet paper, and office supplies at a discount.
  11.  Make sure you charge for vaccination admission and the vaccine itself.
  12.  Use those freebie exam table coverings.  (Yeah, I’m not fond of laying down on an exam table with a paper covered with Viagra logos, but hey, what a poor primary care doc to do?)
  13. Don’t buy new–buy used equipment when possible.  (Checked Ebay lately?)
  14. Consider remote deposit capture.  If you have a big enough volume of checks that come in, you can scan and electronically send the images to your bank to get instant deposits. Cash flow is king!
  15. Consider ancillary services.  See previous post on ancillary services.  See what you can stomach.
  16. Consider group appointments.
  17. Utilize your staff to the fullest.  See previous rants.  Yes, I’m talking to you.

Look, this stuff isn’t fun.  However, if you want to survive, your business (note, I didn’t say PRACTICE), must have revenues greater than expenses.  This is the law of keeping the doors open.  Maybe things will change for the better.  Maybe not.  But if you are doing primary care, it’s up to you how you handle your BUSINESS, and how you keep the doors open so you can see patients.

What if Starbucks billed like ICD-10?

Ah, yes, ICD-10 is coming!  Yes, the new coding system with 10 times more codes than the previous is slated to go live in 2011.  Much of the world now uses ICD-10 because it has more codes, as apparently, we are running out of codes.  You, my beloved provider, will be shouldering the burden of the cost to implement the system.   A few reasons why this has made my normally smiling face curdle with disgust:

 

1.  There are TEN times more codes– all codes will be 7 digits, and then, yes, oh yes! You can add a modifier.  Simple, huh? 

“We are just now beginning to learn the increased costs on physician practices associated with moving to the ICD-10 code set – and they are staggering,” said William F. Jessee, MD, FACMPE, Medical Group Management Association president and CEO.

2.   It ain’t cheap.  Implementing the new coding system is estimated to cost $83,290 for a THREE physician office.  (See http://www.aapc.com/news/index.php/2008/10/icd-10-cm-coalition-press-release/).  At an average reimbursement of $50 per patient visit, that’s an extra 555 visits per year, per physician.  If a physician works 5 days/week, 48 weeks per year, this makes an extra 2.3 patient visits PER DAY!  If patients already feel rushed during their visits, think of it now!  And you know what, there’s not a dang thing the physician can do about it!  (Well, I guess concierge medicine might look more attractive…)

 

3.   You will wait even longer to get paid.  CMS (Center for Medicare and Medicaid Services), which is the government agency behind this change, notes: “…putting in the new system could initially boost by 10% the percentage of claims insurers return to doctors because of coding errors.“   (See http://blogs.wsj.com/health/2008/11/11/look-out-docs-here-comes-icd-10/)

 

4.   It’s another blow to primary care.  Many primary care offices are solo practitioners, or small groups (three or less.)  These are the groups least able to shoulder the cost of another complex government regulation. 

 

5.   You won’t have time to implement it.  You will need to learn the new codes, educate your staff, update your super bills and then change over your billing software to accommodate these new codes.   Most importantly, you will need to do some major cash flow planning.  (Yup, adding in an extra 65,000 codes takes time and money!)  This will be tough to do given the time frame the CMS is proposing.  Even the insurers want more time.  (Who’d a thunk it—me agreeing with medical insurance companies!)

 

6.   Get ready to buy more computers.  If your practice wants to be efficient, you will need computers in each exam room to quickly file the charges.  This is on top of the mandate that medical practies move to an EMR.  (Who’s going to fund THAT?) (See: http://www.ama-assn.org/amednews/2008/09/08/gvsa0908.htm).

 

7.   Beef up your documentation.  You want to get paid?  Prepare to be exacting!  The reason for a medical chart has changed—it used to be so that we could develop a working diagnosis and plan, based on history and exam to treat a patient.  You poor dinosaur! A chart is a way to get paid! 

 

8.   It will drive up the cost of health care.  The cost of soft ware, computers, training, IT support and the like will first be passed to physicians, and then eventually to patients.  There is no such thing as a free lunch!

 

9.    Patient care will suffer.  As physicians, we are ever more focused on computers, documentation, crossing Ts and dotting I’s.  Who will focus on patients when we are focused on coding?

 

10.   We will lose more primary care physicians.  Small practices, in rural/underserved areas can not afford the implementation involved in transitioning to ICD-10.  Implementing  ICD-10 will be a nail in the coffin of areas that desperately need primary care physicians the most.

 

I was thinking about opening a coffee shop.  I could code and bill for beverages as follows: a small cappuccino would be a 99212(01), a medium 99213(02), and a large a 99214(03), and jumbo would be a 99215(04).  I could add modifiers to denote skim, 2% or whole milk.  Shots of flavoring would require modifiers as well. So, a medium, skinny cappuccino with a shot of hazelnut would be a 99213(02)-7-13  (taking into account the ‘skinny’ or -7 and the hazelnut -13.)  I would of course charge you, the customer, more for my nifty billing system.   I also could bill based on how LONG it takes to make the beverage.  I don’t know why Starbucks doesn’t do this.  It seems so efficient.