Staying Afloat in Tough Economic Waters Part 2

So, continuing on with my tale of my little business…I left off describing how ExtraMD ( my local locums company) was going to weather these stormy economic times.  I have noticed a drastic drop in shift requests.  Over the past two years, we have typically had 10 shifts per month unfilled, almost enough for a full time physician.  However, over the last 3 months, I have seen a distinct drop, such that by December we only had 2 shifts that went unfilled.

Scary.

Next, an urgent care cancelled a shift, saying they were so far behind in their receivables, they couldn’t afford any more debt.  We haven’t yet received the money owed for work we did there.

Scarier.

In addition, a large clinic system cancelled over 16 shifts for one month, leaving 4 doctors with out work for February.  They emailed me, saying, “Good news for our clinic…we’ve hired a full time physician, so won’t need coverage.”  Bad news for us.  We do have a 30 day cancellation policy, but the clinic squeaked in at 31 days, so didn’t have to pay the full cancellation fee.

Scariest.

So, what will we do?   How will I find work for my  docs, keep my company afloat and sleep at night?

Here’s my plan:

1. Calm down.
2. Send out a post card mailing, advertising a birthday discount.  (ExtraMD is turning 5.)  Something cute and eye catching will be on the postcard,  like a birthday cake.
3. Email our clients, letting them know we have a birthday  celebration discount going on.
4. Consider taking  birthday cupcakes to our best customers.
5. Put an ad in the local medical journals.
6. Talk to the other physicians in our group about leaving business cards and chatting up the business at practices where they are working.  As the physician owner, I have done all the marketing myself, but hey, it’s worth a try.
7. Create a press release targeting the local market about ExtraMD’s birthday celebration and discount.  Let practices know that we are a  good interim solution during tough times–it’s cheaper to use us than hire another physician, especially if  a practice isn’t certain it can support another full time physician.

I’ll keep you posted as to the results.  How is YOUR practice doing in these tough times?

And Now A Little About Me: How ExtraMD is Weathering the Financial Crisis

If only I could get paid for worrying!  I was up last night at 1:30 am, worrying about my company, ExtraMD.  I formed ExtraMD five years ago, when I left the large hospitalist group I was working for.  The hospitalist group was (and still is!) made up of intelligent, caring physicians.  I earned a nice salary, got regular bonuses and had excellent benefits.  I left because, with a young daughter, I wanted to have greater control over my time.  Exit the benefits, nice salary and bonuses.  Enter flexibility and a steep learning curve with respect to business.

I consulted an attorney, created my company, got a designer to make up brochures and business cards and declared myself in business.  I would eagerly check the emails of my new business email, waiting for work.  I was studying to recertify my boards, and so was glad to have some extra time.  I was thrilled when I got my first free lance job, working for anther hospitalist group.

I realized that the jobs weren’t just going to pour in, so I decided to market.  One of my friends is a rep for a pacemaker company, and he suggested I try the “lunch with the doc” approach.   I dutifully called several offices, got their lunch orders, and, on the appointed day, would show up with the food.  I was lucky if the physicians at the office would even come talk to me.  The office staff was always glad to see me and consume quite quickly what ever offerings I had, leaving me to clean up the office lunch room.  I did get business that way, but hated doing it.   The final straw came when I was asked to bring lunch for THIRTY.  I complied, and the office staff barely said hello as they chowed down, chatting amongst themselves as I sat alone.  The physicians never showed up.   Offices didn’t care that I wasn’t a big fancy drug company, they just wanted free food.  End THAT strategy. Besides, it was so darn expensive and time consuming.   Not to mention how it made me feel!  I now have great compassion for drug reps.

I had already sent out masses of introductory letters and brochures, and got only one job that way.  I decided to try a different approach, and created a post card mailing with snappy color graphics.  I laboriously created a postcard on Publisher, and printed it on my trusty home printer.  I created a database of local physicians by website mining, then printed out labels and got my baby sitter to stick them on the post cards.  This approach got people’s attention, and I started getting more work in primary care and urgent care, which was what I was after.

ExtraMD grew by word of mouth, post card mailings, and ads in the local medical newsletters.  Soon physicians started approaching me to work for my company.  We have grown so now there are 6 physicians, providing “local locums” service through out the metropolitan area where I live.  In the past 4 years, ExtraMD has always had more work than it could handle, and has actively been recruiting physicians.   We now have a controller, a board of directors and a virtual assistant.  Things have been going on swimmingly, with steady growth in revenues and profits.

Until this past October.  Which is why I am up worrying about “my people”.  More in the next post.

Enter the YOUR plan to improve your practice and win an Amazon Gift Card!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

What Will You Be Thankful for NEXT Year?

I work with a business coach, aka the EntrepreneurialMD, who is a physician that helps other physicians who want to think outside the box of medicine.  She sent me a list of questions to ponder.  I have edited them somewhat to tailor them strictly to physicians in medical practice.  Following are items to contemplate as you enjoy that last piece of pie, the sip of wine and the companionship that is Thanksgiving.  If you are really motivated, you might even consider writing down the answers.  (You could do that between commercials during football games.)

– What’s your biggest business/professional objective in 2009?

– What are your biggest opportunities right now?

– Where do you see a gap in your “market” –what’s not being offered?

– What do your “people” (patients/practice partners/employees) complain most about?

– Where are you leaving money on the table?

– What are your top 3 time eaters and energy drainers?

– What is your “Biggest Opportunity Project” for 2009?

– What are the top 5 business/career development strategies you’ll focus on?

– How will you know you’ve had a great year?

 

And to all of our brethren working on Thanksgiving, I give a whole hearted thanks and God Bless.  We have all walked in your shoes, and are grateful for all you do.  Happy Thanksgiving!

See www.entrepreneurialmd.com for more.

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.

As The Medical Home Turns: The Final Installment

Final Installment on As the Medical Home Turns:

Yes, students, today is the last installment in PookieMD’s dissertion on the ‘Medical Home’.  At our last session, we were midway through reviewing the “10 Simple Rules for the 21st Century Health Care System,” rules to guide the redesign of the health care system.  These guidelines were put out by the National Committee for Quality Assurance.  Why are we torturing ourselves with this tedium?  Because this may the  measuring stick by which CMS (Center for Medicare and Medicaid Services) will use to reimburse our practices.  And that means, of course, insurance companies will follow suit.  Following are rules 7-10 with my pithy commentary:

 

“7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”

Item 7: “The need for transparency.” To me this sounds very similar to ‘rule 4’, free flow of information.  The salient feature is that the health care ‘system’ should make information available to patients about health plans, hospitals…etc.  Who will be responsible for each aspect–are physicians to review a patent’s health plan with them, and review each hospital the patient may go to?  This is an incredibly broad assertion of what needs to happen, but with no clear plan of who exactly needs to provide this information.  Part two, which references the “system’s performance”, appears to be directly related to measuring safety (think the never/ever no pay rules, for example), and also appears that your practice will be measured on evidence based practices and patient satisfaction.  We already discussed evidence based practices, which I consider the basis of modern Western medicine. However, the patient satisfaction issue is murkier.  What exactly IS patient satisfaction?  Would I get higher scores if I didn’t collect copays, gave out lots of oxycontin and ordered any test the patient saw on TV?  Clear criteria need to be established,  e.g. are patients seen with in 15 minutes of their appointment?  Are appointments accessible on a daily basis?  I’m not buying the criteria of “Rate PookieMD on a scale of 1 to 10–where one is the worst physician you ever saw, and 10, PookieMD is better than Marcus Welby, House and Hawkeye Pierce combined.”

Item 8: “Anticipation of needs.”  Yes, indeedy, I certainly try to anticipate my patient’s needs.  More importantly I try to anticipate outcomes.  If I do x, y will happen. But, I also try to have a plan in case z happens.  I can’t anticipate a patient’s every need, but I can use the best of my knowledge and resources to try to move the patient toward health.  Anticipation of needs smacks of wand waving, rather than reality.  Anticipation of outcomes is medical science, and an attainable goal. 

Item 9: “Continuous decrease in waste.”  Sounds good to me.  I hope that includes not wasting MY time filling out endless forms and jumping through hoops to make the ‘Medical Home’ a reality.  It is interesting that the Rules state the health care system should not waste resources or patient time, but makes no mention of physician time.  I’m all for decreasing waste, and hope that much more in depth thought goes into developing the operations and processes of the ‘Medical Home’, so it is not a gigantic bureaucratic wasteland.

Item 10: ” Cooperation among clinicians.”  Please do not patronize me.  Cooperation is a kindergarden skill, and doesn’t belong on this is on the list.  The physicians I know and work with are dedicated and caring, and certainly cooperative.  We don’t always agree on management, which is HEALTHY, and we certainly can be snappy when fatigued, but I think this is rule is over kill.  Shall we form a circle and sing Cum By Yah?

So my final take on the “Medical Home” is that it is a bunch of ‘rules’ that primary care  practices are trying to do already.  (Or as close as they can get with the limited resources they have.)  What it woefully neglects is how systems should be put in place to make health care, health information technology, and a much needed emphasis on PATIENT CENTERED care a reality.

Back to the drawing board.  This time, make sure you invite the physicians in the trenches that actually do the work–the family practice physicians,  the internists and the pediatricians, to guide the guidelines.

Resuscitating Primary Care, Part I

 

As promised, I will turn my laser like focus to the task of “fixing” primary care.  I will examine both micro and macro ways of doing this, coming up with to do lists that physicians can implement in their practices as well as global suggestions that will take shifts in health care policy.  (Which only we as a group of physicians can enact!)

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!

Ancillary Services as a way to Increase Revenues (?)

It was with great interest that I read the Medscape article, “Ancillary Services in Primary Care,” posted today on Medscape Internal Medicine.  The author, Leslie R. Kane  (okay, I can’t help it but I immediately thought arcane,)  goes through several strategies to boost revenues.  She investigates botox, dermal fillers, lab/lab draws, holter monitors, laser hair removal, and weight management clinic.  After reading the article, I was struck by the thought, “Is this why I went to medical school, to remove hair and plump up crows feet?”  Additionally, the weight management clinics use herbal remedies and prescription medications.   Kane interviews an internist, Dr. Larry Maguire, and he states, “”I mainly do medication-focused weight loss, using the medicines that are currently available, plus some new ones.”  I query the use of prescription and OTC medications  (remember fen-fen?) and wonder about the medical legal aspects of these programs.

I think there are two take away messages: 1) look before you leap!  Carefully analyze each opportunity with respect to additional costs, cash flow (!) and revenues.  Make sure you can afford to offer these procedures, knowing there may be a time lag before you see actual revenues.  Be sure you develop a budget for marketing and a marketing plan as well.  2) Think carefully about why you practice medicine.  If you are passionate about frown lines and unwanted hair, go for it!  Otherwise,  would  your time be better served lobbying for better reimbursement and looking for ways to maximize efficiency?

Hmmm, I’m thinking of having a little work done, perhaps these frown smile lines….