Julie Knudson

Changes are a constant in the healthcare industry. From shifting reimbursement models to a growing paperwork burden, the longstanding approach to practicing medicine is often unrecognizable in this new environment. In response, the traditional physician job path is also evolving.

Sixty-nine percent of respondents in the 9th annual 

 reported that they would consider going part time. And while about two-thirds (64 percent) of respondents don’t want to change workplaces, 29 percent said the main reason why they would prefer to work somewhere else is to work better hours or achieve greater work-life balance.

 A growing number of respondents (46 percent) said they would consider becoming a locum tenens physician, suggesting the traditional work environment is no longer as appealing to the 91 percent of respondents who have been practicing at least 11 years.

Today, physicians are increasingly open to the idea that they no longer need to be-or perhaps even want to be-tied to a single employer. Portfolio careers, where physicians have the flexibility to pursue multiple areas of focus and manage multiple revenue streams, are gaining traction. This strategy can provide high levels of job satisfaction, some much-desired mental stimulation, and a good income, too.

It often begins with a desire to make learning a lifelong endeavor and to keep things fresh. “There are so many things I’m interested in, so if you told me I could only do one thing I’d struggle with that,” says Heath A. Jolliff, DO, FACMT, an emergency medicine physician in Columbus, Ohio. Multiple passions are a common thread among doctors who pursue portfolio careers.

Jolliff noticed that working in the ER brought challenges that fascinated him, and it didn’t take long for him to realize there weren’t many others focusing on them. This gap in expertise provided Jolliff an opportunity to pursue something new and interesting. He’s dedicated himself to emergency medicine for 25 years, and for the past 18 years he has also worked in the subspecialty of medical toxicology.

Today, he satisfies his passion through clinical teaching jobs at two different hospitals, 

Ohio University’s Heritage College of Osteopathic Medicine

. These roles give Jolliff a way to share his vast knowledge in the areas of emergency medicine and medical toxicology (and to promote a similar passion) with medical students.

In addition, Jolliff owns his own company, 

, a firm that provides consulting to a variety of clients-patients, physicians, and legal teams-on toxicology issues such as evaluation of potential poisonings, forensic reviews, risk assessments, and similar expert analysis.

Heidi Moawad, MD, didn’t set out to have a portfolio career. Like many doctors who find themselves taking on new or additional responsibilities, she started by pursuing areas of interest. Along the way, she sought out a schedule and workload that best fit her growing family’s changing needs.  

While practicing neurology, she began talking with fellow physicians about ways to shape a career that suited her preferences. A number of her colleagues expressed similar desires, but during these conversations Moawad discovered there was very little information available about nonclinical jobs. She decided to write a book on the subject, a move that brought her into the publishing world.

, she also taught at a nearby college. Both of these roles were part time, a structure that offered her the flexibility she needed to care for her young children. Additional writing work, mostly small contracts in the early years, followed as she developed the right relationships.

These linked but disparate roles didn’t replace Moawad’s income from her neurology work right away, but she gathered more work in the following years. She now holds faculty positions at 

, both in Cleveland, Ohio. Today, her time commitment and reimbursement, plus teaching, writing and consulting work, are on par with a full-time clinical neurologist position.

Trained in emergency medicine, John Shufeldt, MD, FACEP, has created a portfolio career that embodies his strong entrepreneurial spirit. Shufeldt’s work in emergency medicine afforded him flexibility, and he scheduled shifts that allowed him to continue his education in other areas. He obtained a Master of Business Administration, a juris degree, and an airline transport pilot rating-all while practicing medicine.

In addition to practicing emergency medicine, Shufeldt is the medical director of the Phoenix Police Special Assignments Unit, where he goes on high-risk calls with the SWAT team. He’s also the founder and CEO of 

 a telemedicine services company that fits well into the mobile device-heavy culture of today’s patients. In 2015, Shufeldt launched 

, a firm that partners with the federal Indian Health Service agency to provide emergency department staff for reservations’ hospitals. This latest endeavor came about as a result of Shufeldt’s Six Sigma certification and process improvement work.

A prolific author, Shufeldt has written a number of books, including urgent care textbooks that draw on his nearly 30 years of experience and a series of 

 books that delve into being-and becoming-a high achiever. Along with mentoring medical and pre-med students, sharing what he’s learned to help them prepare for their medical training, he helps them get published. Shufeldt is quick to point out that mistakes are part of the growth process, but adds, “A lot of what has come together to make my career is learning from those mistakes.”

Simply making the decision to have a portfolio career isn’t enough. When doctors finally decide they want to take action, determining the logistics can be daunting. Can I do this while my family is still young? Am I too old to make such a big change? How will I make ends meet in the interim?

It’s not uncommon for doctors to take several different approaches and a bit of trial and error before discovering the mix of jobs that works best for them.  A position as a writer or editor appealed to Moawad, but she was uncertain about such a move at the time. Market and economic pressures may also play a role in finding just the right blend.

Moawad says a pay gap should be a realistic expectation for many doctors as they transition from full-time practice into a portfolio career. They should also be prepared for changes along the way. For example, Moawad spent some time working in telemedicine for a small company that later went out of business. Whether it’s the end of a company or just the end of a contract, a portfolio career means that doors will occasionally close. The trick is keeping an eye out for new ones to open.

Jolliff knew he wanted to deepen his expertise in medical toxicology during residency, but the prospect of spending even more time as a student when he could be making money caused him to put the idea aside. “It was a huge challenge because I finally felt I was done with school, and I needed to pay off those loans,” he recalls.

The money side of the equation often looms large in the overall picture. Jolliff’s passion was ultimately enough of a driver and, after spending a couple of years stashing funds away, he moved to Denver for a fellowship. He admits it was financially difficult, but says, “I’ll never regret it. I learned so much. It was absolutely worth it.”

Moawad still occasionally conducts independent medical exams but, by and large, she’s no longer practicing medicine. “Medical malpractice insurance is expensive and it’s hard to get it prorated if you want to work a very small amount of time,” she says. Until a few years ago, Moawad volunteered at a free clinic, a position that provided free malpractice insurance as part of the deal.

Malpractice insurance is something physicians may find difficult to navigate. Cutting back on direct care hours could mean the income won’t cover the insurance costs. In some cases, the insurance could make it difficult to practice clinical medicine on a part-time basis.

Finding the time to cultivate additional knowledge or skills-whether they take the shape of formal training or on-the-job learning-is often an early hurdle for doctors looking to develop a portfolio career.

At its core, medicine is a dynamic, ever-changing field. Taking an active role in advancing where physicians can contribute their skills and expand their knowledge can be hugely rewarding. If juggling everything seems overwhelming now and then, Shufeldt says the end result can be well worth it. “I think you have to realize that you need to be multidimensional to really have a successful practice and a balanced life.”

a Seattle-based freelance writer specializing in healthcare and technology.

Articles

A growing number of physicians are taking their careers and schedules into their hands through multiple part-time jobs and revenue streams.

Pursue your passions with a portfolio career

Studies have shown an increase in physician burnout in recent years, and those 

 aren’t likely to improve any time soon. Burnout is a common factor behind job dissatisfaction along with a lack of work-life balance and ongoing stress levels. Add to that decreasing reimbursements and increased administrative burdens, then sprinkle in some boredom and repetition. No wonder doctors sometimes wonder what happened to the art of medicine.

For these reasons and many others, physicians may consider leaving the ranks of daily medical practice to start a new adventure. Some doctors may move into consulting or join a tech firm, while others seek careers on the periphery of the healthcare sphere. No matter where their path takes them, changes in the medical field are not uncommon.

However, some doctors may consider a career change and hit a wall almost immediately. Julia Pewitt Kinder, DO, says physicians’ first response when they feel the desire to do something that doesn’t involve patient care is to try to talk themselves out of it. She says the most common protests she hears in her consulting business, Physician Career Opportunities, revolve around the time and money doctors have already invested in their career, education loans for which they may still be paying. “They say, ‘Why would I consider changing? That would be crazy. I’m respected, I make a difference, and I make a good living.’”

It can be difficult-and families aren’t always supportive-but acknowledging they deserve to be happy in their jobs may be the first hurdle many doctors need to overcome. Once physicians realize they no longer want to focus on clinical practice, the prospect of changing their career path can be daunting. Throughout their extensive medical training, no one ever talked about career transitions, and they don’t have a clue where to go from here.

Many doctors are reluctant to ask for help, but Peter S. Moskowitz, MD, encourages them to reach out to a career coach who understands medicine and can provide the necessary support. “It will shorten the transition time dramatically and save doctors a lot of heartache by having someone to help guide and mentor them through the process,” says Moskowitz, executive director of the Center for Professional and Personal Renewal and emeritus clinical professor of radiology at Stanford University School of Medicine.

An honest assessment of potential career directions, along with a physician’s skills, abilities, values, and work preferences is key to success. It’s also a process that can be difficult for physicians to follow, especially those who have already been unhappy for a long time. Heather Fork, MD, CPCC, owner and founder of Doctors Crossing, encourages physicians to view the transition as a journey and an opportunity to find out more about themselves. She also reminds doctors they don’t have to find one “perfect” career to transition into. “You already did that when you became a doctor, but that’s not where you wanted to stop,” she says, adding she recommends doctors consider several career possibilities.It’s not easy, says Michelle Mudge-Riley, DO, MHA, RDN, founder and CEO of Physicians Helping Physicians and Docibr in San Antonio. “The fact is, it’s messy. That’s just the reality,”  Mudge-Riley says of her own career shift and the transition process other doctors encounter as they move away from clinical practice. But in the rush to find something other than clinical work, physicians sometimes overlook figuring out what they want and need. Mudge-Riley acknowledges it can be a long and arduous process, but unless doctors have a clear idea of their larger goals, that longed-for job satisfaction may continue to elude them.

Determining how-and when-physicians should explore a career shift can be difficult. Pressure from colleagues as well as family, not to mention internal guilt, doubt, and fear may lead doctors to simply stay the course, even if that means an unsatisfying career. But there are other paths, some in medicine and some not, that allow physicians to transfer their hard-earned skills as they pursue their passions. Four doctors who forged ahead and made a career transition share the lessons they’ve learned.

After 17 years in a busy hospital-based private clinical radiology practice, Moskowitz experienced significant professional burnout. The effects were devastating and impacted his marriage, his children, and even his health. “It forced me to confront the fact that my work life was killing me and my family,” he says. Moskowitz, then a managing practice partner, took time away to gain perspective. As he focused on getting healthy and adopting a better work-life balance, he began to see more clearly just how much he disliked his job.

Moskowitz knew his long-term happiness rested on making a career change but didn’t know what he might do as an alternative, a situation that created a lot of anxiety for him. Having never heard of career coaches or similar support systems, Moskowitz struggled along on his own. Through his reading on career options and managing career transitions-along with recovering from burnout and dealing with competing pressures of stress, family dynamics, and job satisfaction-Moskowitz discovered he was drawn to those issues far more than radiology.

He volunteered at his son’s boarding school, where he acted as a facilitator for parent-student discussion groups. Moskowitz enjoyed sharing his experiences with other struggling parents. It was an illuminating moment. He realized his skills and background perfectly aligned with his growing desire to provide coaching support for other doctors coping with the same stress, burnout, and career and family difficulties he faced.

Moskowitz completed a coaching certification training program in 1998 and opened a physician coaching practice the same year. Today, he is retired from clinical radiology and estimates he spends about half his time doing one-on-one career and life coaching for physicians throughout the United States and Europe. He claims he spends the rest of his time playing, but his professional productivity is as high as ever. Moskowitz’s second book on physician career management was published in 2017, and he continues to participate in keynote lectures and workshops. It’s evident Moskowitz loves lecturing, teaching workshops, writing, and coaching. He says he derives immense satisfaction from knowing he has made a difference in the lives of thousands of physicians over the past 20 years.

For Mudge-Riley, a longstanding unhappiness ultimately led her to shift her career path away from practicing clinical medicine. She had already come to grips with the fact that she didn’t enjoy direct patient care, a realization that drove an initial move into pathology. There, she found the culture to be so negative and the environment so toxic that she knew she couldn’t stay. “I wasn’t willing to spend the next 40 years being one of the angry and burned-out doctors I saw all around me,” she says.

Feeling stifled and dreading the future, Mudge-Riley took a year off from clinical practice and worked for a medical device firm. One year turned into several years, during which she got a business degree while continuing to explore her options.

“I felt alone, like I was a huge failure,” she recalls. “It was pretty awful.” Despite the support from friends and family, Mudge-Riley felt very alone in her pursuit to find a career outside clinical practice. She was surprised when her speaking and outreach efforts started prompting other doctors to approach her with tales of their own job dissatisfaction. Learning that others in the clinical profession harbored similar longings for something that didn’t involve practicing medicine, Mudge-Riley began sharing her story more widely. As she helped other physicians forge new careers, her own coaching business grew organically.

Her planned return to clinical practice never happened. Instead, Mudge-Riley estimates she focuses 80 percent of her time coaching and mentoring other physicians in some capacity. She conducts workshops, spends one-on-one time supporting doctors who are in need of their own career adjustment, and travels to different organizations to help address workforce issues from the inside. Never wanting to find herself in a situation where she’s unsure what she’ll do next, Mudge-Riley maintains other areas of interest, too. She consults on wellness for Fortune 500 companies and teaches a course for undergrads at a university.

Sometimes things happen in life that make clinical practice a less attractive, even impractical, full-time career. Pewitt Kinder was just out of residency when she and her husband had their first child. Ella was born with an extra chromosome (Down syndrome), so Pewitt Kinder wanted to ensure she could devote time to maximizing Ella’s developmental potential. Knowing there would be a lot involved in raising her, Pewitt Kinder’s first goal was adding flexibility to her career schedule.She was frustrated by the lack of information available at the time about childhood issues she expected she’d face, such as teaching Ella to crawl, walk, and potty train. As she navigated those waters, Pewitt Kinder sought to tweak her career further so she could speak with and consult other parents who had many of the same questions she did.

A few years later, Pewitt Kinder had twins. One was born with multiple medical problems, making a career of clinical medicine even more difficult. But Pewitt Kinder still wanted a career, still wanted to be a mom, still wanted to do it all. Quitting work to be a stay-at-home mom wasn’t going to cut it, but neither could she continue clinical practice full time and still give her family the attention they needed. She asked herself what she needed to do to make it happen.

Pewitt Kinder, like many physicians who have transitioned away from daily clinical practice, now enjoys a portfolio career-where multiple part-time jobs replace the traditional single revenue stream-that combines several different occupations in order to meet her many goals. “I discovered there wasn’t one job that checked all the boxes for me,” she explains. The process took more than a decade of trying different things, adding a job here and cutting back on clinical practice there before eventually finding a way to fit everything into the puzzle.

Today, Pewitt Kinder has two consulting businesses: one working with new parents who have children with Down syndrome and the other helping doctors navigate the career transition process. She also works for a hospice company and a major health plan. All of her jobs are done from her home Tennessee, but Pewitt Kinder’s arrangement still offers occasional travel. She also has opportunities to speak at conferences and workshops. Altogether, she says she makes good money. It isn’t the traditional path most doctors envision at the outset of their careers, but Pewitt Kinder says it’s a path that has worked for her.

Fork enjoyed her dermatology residency and immediately purchased a private practice in Austin, but she was questioning her career path after four or five years. She found gratification talking with her patients during longer procedures, but shorter visits left her with little opportunity to get to know people. She made some changes to enjoy her work more. Nine years later, things had improved, but Fork still felt there was something else she was meant to do. She just didn’t know what that was.

Seeking space to find out what came next, Fork took what sound like drastic steps. “I left medicine, sold my house and everything in it, and I lived in an 800-square-foot cabin out near Willie Nelson in the Texas hill country,” she says. It isn’t something everyone can do, but it worked wonders for Fork. She had the time and space to do some volunteer work and ruminate on things she enjoyed without the pressure to make any of them a bona fide career path.

When she was ready to think about what was next, it took Fork only two weeks to settle on a course. Fork says it was obvious to her that she she should coach and help others figure out their career paths. She launched her physician career coaching firm nearly nine years ago.

Fork continues to support other doctors as they find their own answers about what they want from their jobs and develop a strategy to get them where they ultimately want to be. And in helping others, Fork found a way to help herself lead the life she always wanted-just not in the way she initially imagined.

The right support and a thoughtful strategy can maximize job satisfaction for physicians who are ready to transition to a second career.

So you no longer want to practice medicine

The good news about lawsuits: You can take targeted steps starting today to minimize risks in the future.

Minding legal obligations around employer-employee relationships, showing genuine concern for patients and staff, and treating anger or unhappiness in the practice as legitimate issues are just some of the ways physicians can reduce the risk of a lawsuit.

Write (or rewrite) your employee handbook

In the employee-employer relationship arena, it’s important to have a good handbook that addresses both federal and state law issues, says Matthew Fisher, JD, partner and chair of the health law group at Mirick O’Connell in Worcester, Mass. States may have specific requirements around maternity and paternity leave, for example, or how much (if any) notice a practice can demand employees provide before taking sick or personal leave. By becoming familiar with their rights and obligations as employers, physicians and practice managers can reduce their risks of litigation stemming from human resource problems.

Fisher encourages physicians to avoid a “head in the sand” mentality, where a lack of past problems leads them to believe they’re in the clear. Practices should be proactive, thinking ahead about how to implement the necessary protections and promote an appropriate workplace environment. The strategy will require the investment of time and money in compliance and developing good employee relations. In the long run, though, Fisher says this will prove beneficial. “If someone starts to worry about something, it will be reported up and you can work your way through it before it becomes a lawsuit.”

One approach that can be tremendously helpful is to form risk committees in the practice, and for physicians to actively participate in identifying high-risk areas, says Diane C. Fernald, RN, JD, vice president of education and consulting services at Med-IQ, headquartered in Baltimore. If those at the top make it clear they recognize that medicine is a risky business, everyone in the practice is in a better position to identify and bring forward any potential liabilities. A medical assistant may notice the practice lacks a location where they can speak quietly during patient intakes. “If they feel that no one will snap their heads off if they go directly to the head of the practice and say, ‘I think we should be doing things differently,’ then people are more likely to suggest ways to improve the practice,” Fernald says.

Another strategy involves implementing a daily huddle where staff come together to plan how to handle whatever’s on the schedule. The effort can be as simple as a five-minute discussion that covers a quick rundown of the day’s challenges-calling attention to elderly patients who might need extra attention, for instance, or developing a plan to deal with an unplanned staffing shortage. Practices that are proactive about spotting potential problems and having a solution at hand can circumvent a number of common risks. “They make it part of their professional practice to recognize it, understand it’s something they have to deal with and then work as a group to try to identify their risks and what to do about them,” Fernald says.

General communication skills can be improved by looking at interactions from the patient’s perspective. “There’s no element more important to avoiding a malpractice claim than a healthy doctor-patient relationship built on clear and effective communication between one another,” says Samuel N. Klewans, JD, a partner at Grad, Logan and Klewans, a law firm in Falls Church, Va. He suggests physicians try putting themselves in their patients’ shoes, viewing interactions from their perspective. Putting time into patient relationships outweigh concerns about already too busy schedules. People expect timely replies to calls and e-mails. Don’t rush through appointments. “Your patients are very concerned with their health, and when they’re meeting with you, they want to believe you’re very concerned about them, too,” Klewans says. Showing empathy and taking the time to fully answer patients’ questions during the visit can go a long way toward making them feel comfortable.

Even as other risk areas are addressed, reducing the risk of a suit can sometimes be tricky. Unhappy patients and disgruntled employees are equally likely to file suit against someone they feel has wronged them, and who was vindictive or insensitive in the process. “I would say the leading trigger is the loss of employment, which may well be justified,” Mustokoff says of claims filed by staff against a physician. From the patients’ standpoint, sensitive discussions that take place in public areas such as waiting rooms, the hallway outside an exam room may appear thoughtless or mean spirited, even if that wasn’t the intention. “The number one thing would be a prompt investigation of all complaints, and a response made to the complaining party,” Mustokoff says. From there, physicians should continue monitoring the situation until it’s resolved.

Now more than ever, it’s important to take proactive steps to prevent being sued.

4 ways to reduce the risk of a suit

Forget golf or tennis. “Litigation has become America’s favorite sport,” muses Samuel N. Klewans, JD. With lawsuits seemingly everywhere, and with fewer people putting doctors on a pedestal in today’s consumer-driven healthcare environment, physicians could be forgiven for feeling like they’re on the front lines of this new sport.

Though the healthcare landscape has changed dramatically over the last decade, today’s typical lawsuit isn’t all that different from years past. However, the tactics of individuals pursuing litigation may be changing. “There is more willingness to try to get creative with claims,” says Matthew Fisher, JD, partner and chair of the health law group at Mirick O’Connell in Worcester, Mass. He references a recent decision in Connecticut that reflects this trend, where the release of an individual’s record may not have been handled appropriately and the state recognized there could be a state-level breach of privacy. Different locales have taken it upon themselves to initiate privacy legislation, making it more critical than ever that physicians are aware of what’s happening where they practice rather than simply monitoring rulemaking at the federal level.

Society may have become more litigious, but that doesn’t mean physicians need to take the brunt of it. Outside of medical errors, there are some common mistakes physicians make that are likely to result in a lawsuit. Knowing these risks-and having a strategy to address them-can help reduce the chances of becoming a target.

While medical mistakes often get the most attention, “the biggest risks do not necessarily arise out of the role of being a doctor,” Fisher says. Instead, owning a practice may present more opportunities for errors. The absence of policies to guide interactions with staff, whether they’re other doctors, licensed professionals, or nonprofessional staff, is one primary area for concern.

Without clearly defined policies and procedures in place, everyday activities can become legal landmines. Workers may find seemingly simple tasks such as getting the time and pay they have coming to them inordinately difficult. Fisher says a suit may arise through a failure to provide the appropriate type of time off or having an outdated policy. If employees feel they’re being shorted by the practice, they could pursue a claim.

Diane C. Fernald, RN, JD, vice president of education and consulting services at Med-IQ, headquartered in Baltimore, says that what she calls “transactional or process errors” lead to more malpractice cases than medical errors. Documentation is one area of focus in many lawsuits and poor or insufficient documentation practices can put physicians on risky legal footing.

Even giving a patient accurate information but not writing it down might lead to trouble years later. The passage of time dims the physician’s recollection, and the busy nature of the practice environment only compounds the problem. “You’ve seen hundreds of patients since then and there’s no way to remember with any clarity what you said or did,” Fernald says. With little defense at hand, a claim might not be far behind.

Patients want to know what’s going on with their health, but physicians make communication mistakes that muddy the waters. Rather than being clear and consistent, doctors tend to use medical jargon or offer confusing descriptions of health conditions and the planned treatment strategies. “Many patients, particularly those with less education or lower economic classes, are too embarrassed to ask what the doctor means or what they’re talking about,” says Klewans, a partner at Grad, Logan and Klewans, a law firm in Falls Church, Va. He has experienced this lack of translation himself. “It has happened to me with doctors, and I said, ‘Tell me in English, something I understand.’” If a physician seems to be speaking a different language, patients may not even know what questions to ask.

Patients who feel their provider has been thorough, that everything was explained to them along the way, are less likely to pursue a claim if there’s an unexpected or unwanted outcome. “But if the physician is not communicative, he’s going to get sued,” Klewans says. “As a caregiver, it’s the doctor’s job to help patients feel comfortable.” Patients’ families are also a frequent part of the equation, something physicians don’t always consider. When patients and their loved ones don’t have a good understanding of the care and planned procedures, a lawsuit could be on the horizon.

Perhaps the No. 1 way physicians can guarantee they’ll be the served with a lawsuit is extraordinarily simple: Be a jerk. Michael Mustokoff, a Philadelphia-based partner at law firm Duane Morris, says patients have expectations for how providers behave based on their previous experiences and what they see on television. These idealistic personages can include Marcus Welby, Trapper John, and Greg House.

What patients don’t expect is to be treated unkindly because their physicians are stressed by the rigors of running a business, or because they must sacrifice time providing care to deal with nonclinical issues, such as reimbursements and licensure headaches. “When the most careful, astute and skilled physician makes a mistake-and they all do, no one is infallible-how the patient regards the effort is every bit as important as their result,” Mustokoff says. If the physician is a jerk in those circumstances, the mistake is amplified. Patients who feel wronged may see a lawsuit as a fitting redress.

Technology has also shifted the risk picture. It streamlined many historically time-intensive tasks, but it has also created opportunities for new types of mistakes. The copy-and-paste function is a good example. Fernald acknowledges it makes data entry quick and easy but warns it can be a detriment if it’s used without sufficient attention to detail. Erroneous information can easily be added and then inadvertently perpetuated within the patient file, for example, potentially planting the seeds of a lawsuit down the road. “The other providers who are looking at the record see the bad information instead of what’s really going on, and then decisions are made on inappropriate data,” Fernald explains.

Julie Knudson is a freelance healthcare writer located in Alexandria, Va. 

These common mistakes can put you at risk of a lawsuit.

5 guaranteed ways to get sued

The traditional raise isn’t so traditional anymore. Due in part to declining reimbursements and other struggles, some practices are finding themselves short when it comes to handing out yearly pay increases. The 2018 

 Staff Salary Survey revealed that 13 percent of respondents have frozen or even cut workers’ salaries.

That doesn’t mean there’s less for employees to do. One challenge identified by 36 percent of survey respondents was dealing with increased workloads and employees who performed dual roles within the practice.

Knowing where financial and workforce difficulties intersect, practices are increasingly trying to get more out of staffers despite being unable to pay them more money. It’s tricky, but it is possible to juggle the issues of workload and pay.

Evaluating the need for staff against existing workloads is often a good place to start.

“There’s information that shows that overstaffing and understaffing are equally bad,” says Juliana Stanley, MBA, CMPE, practice management consultant at the Texas Medical Association. “If you’re overstaffed, you have too many people that you’re paying to do the same tasks. If you’re understaffed, you don’t have enough people to bring in the revenue that you need.”

Instead of increasing or decreasing headcount, she suggests it may be more effective to focus employees’ time on the tasks that matter most.

“It’s common in small practices to try to do more with less,” Stanley explains. “We have data that shows if you staff properly, instead of three staffers for billing and coding maybe you have three and a half or four, for example, you’ll make more money because you can bring in the revenue that’s generated.”

The strategy is also linked to what Stanley refers to as “hitting that cultural reset button,” where physicians ensure that everyone in the practice is on the same page. Establishing a culture centered on patient care can be useful in centering the staff’s efforts as well as creating job value and satisfaction without increasing salaries.

“We can take better care of our patients if we’re doing things really well, and when everyone is on the same page, employees feel more valued and empowered in their jobs,” Stanley says.

Shuffling responsibilities-either to better consolidate similar tasks or to take advantage of particular skill sets within the practice-may make existing employees more efficient.

At April Gardner DO and Associates Inc. in Lebanon, Ohio, practice administrator Alicia Overman, CMM, says over time, individuals hired to work at the front desk have evolved into other roles. They’ve gained knowledge about the practice’s operations and found ways to expand their skills.

“We’ve had some move to the back to become MAs, and then we’ve had one who started at the front desk and has now moved into a care manager role,” she says. The change has allowed the practice to shift some of the responsibilities away from the clinical staff and add it to the care management basket.

The care manager position now focuses on prior authorizations and the chronic care management program via telephone with patients, Overman says, reminding them of things such as getting labs done and checkup reminders. Clinical staff no longer need to take time out to handle these types of tasks, but patients still receive the level of care they require and the practice maintains a focus on the revenue cycle.

Making the most of clinical staff may require some additional considerations. Kate Othus, MHA, partner and healthcare consultant at Aldrich Advisors in Lake Oswego, Ore., says one area to think about is “making sure they [physicians] have the right types of licenses in their practice.”

Because some states have made changes to LPN, RN, and other licenses, it might be worthwhile to reevaluate how those workers are best utilized within the practice. “It’s about what each of those different levels of employees cost, plus what’s the best and most needed for your specialty from a clinical standpoint,” Othus explains. If practices can add additional responsibilities or roles that are currently distinct are combined, it may factor into how many employees are needed and how they are compensated.

Employees are frequently willing to put in some extra effort without extra pay when they see that they’re appreciated. For Administrative Professionals’ Day, for example, Overman says that Rose S. Ebel, DO, the practice’s main physician, treated everyone to lunch.

“We recognize a job well done,” she says. When someone from an outside facility called to commend one of the practice’s employees for being particularly helpful and going above the call of duty, Overman says, “We got a little gift card for that staff member.”

Non-traditional work arrangements may be another option in some practices. Though not typically costly to implement, the ability to work remotely can be a powerful perk for employees. Physicians should be mindful, though, to be sure it’s a viable situation for their practice’s particular needs.

Overman says her team tried it at one point with their billing role, but it didn’t work as well as expected. “It leads to isolation from coworkers and they don’t feel they’re part of the group,” she says. “We also saw lower production and even lower accuracy with them being outside the office.”

The use of flex hours can sometimes be added to give employees with a perk outside the paycheck. “It’s tough with a smaller staff, but there are ways to do it,” Overman says. Even providing the ability to shift working hours earlier or later one day a week could offer staff the opening they need to run errands or spend more time with their families, both of which can help make job satisfaction about more than the amount of a paycheck.

Alternate benefit strategies, such as the availability of voluntary benefits, wellness programs, and similar extras, are also employed by some practices to encourage workers to do more without increasing salaries. But Stanley cautions that any program must be carefully implemented. “The problem is that, when we give people non-monetary compensation, we need to put a value on that so it doesn’t get taken for granted.”

The solution doesn’t need to be time consuming to track or communicate. It can be something as simple as a line on a paystub that indicates the portion of medical insurance paid by the employer. “When I see how much they take out of my check for medical insurance, I can see how much they pay, too,” Stanley says.

The practice environment also lends itself to recognition programs, which Stanley says are “super helpful and can be very inexpensive.” Patients often don’t feel well (thus the reason for their visit), but they’re increasingly expected to pay more for services that used to cost them less out of pocket.

For office staff and care providers, it can sometimes be a thankless job. “When an employer says, ‘You did a good job, here’s a ticket to a movie,’ that’s really cool,” Stanley says. A quick email to everyone in the practice touting the great thing a team member did can be equally appreciated, not to mention a morale boost for the whole group, especially if things seem uncommonly dreary. “You want to thank those people who busted their tail,” Stanley says. An extra gesture here or there can often fill the gap when paychecks are static but expectations of employee performance isn’t.

Even if alternate work arrangements aren’t suitable, practices might consider providing flexibility through a paid time off (PTO) or similar program. This gives employees the ability to take time off when needed without committing to a long-term alternate schedule.

“That can be tough in a small practice because you may not have coverage,” Othus says. Though that barrier exists, it’s still a strategy that could be hugely beneficial if there’s a way to make it work. “It’s been successfully implemented and it has translated to employees as a feel good,” she says.

Holidays could also be used to provide employees with a perk that doesn’t require a traditional raise. “Think about your patient base and when your popular appointment times are,” Othus says. “Could you afford to add a holiday, or maybe just close the office and allow employees to choose if they want to take it as PTO or as unpaid?” Whether planned around school breaks or holidays, staff appreciate the opportunity to spend extra time with their families and loved ones. They’ll also be reinvigorated during working hours to crank up their productivity.

Giving employees the ability to attend training-either on-the-job or in a more formal educational setting-is another benefit that can sometimes take over where the paycheck ends.

“Additional training is beneficial for both the employee and the employer,” Othus says. “Encourage them to go annually to some type of course that’s applicable to their role.” And though advancement opportunities in smaller practices may be more difficult to provide, offering workers a chance to expand their skills is still valuable to everyone involved.

When tasks come along that fit their increased knowledgebase, an employee is more likely to agree to take on that additional responsibility.

The topic of pay can be uncomfortable, especially when there’s little room in the budget for higher salaries. If a physician or practice manager thinks talking about financial arrangements with patients is bad, they’re really going to dread telling employees their paychecks won’t be going up any time soon. With a few tips in mind, it is possible to make compensation discussions less awkward.

Physicians should begin by setting employees’ expectations around salary increases, both the timing (tied to yearly performance evaluations or a separate compensation cycle, for example) as well as the likely amounts.

“It’s important from the get-go-from the hire date-that you let employees know,” Stanley says. “Tell them if you do performance evaluations and if you do or do not give annual bonuses or whatever else you might offer during the year. Also, tell them there may not be a raise at every single performance evaluation.”

If the rest of the local economy seems to be bustling but the firm simply can’t afford to bump pay rates, it’s important to be as honest and transparent about the situation as possible. Employees often don’t understand the business’s financial strains if they aren’t on the front lines of balancing the books. “Say that you’re putting a hold on raises right now,” Stanley suggests.

No matter which philosophy the practice adopts about annual raises, Overman encourages physicians to think about compensation in all its forms throughout the year. Recognizing a job well done, ordering lunch for the office, and handing out small incentives such as gift cards when someone goes the extra mile go a long way.

“Then when the time comes for the evaluation talk, it helps employees realize there are other perks of being at the practice besides the money,” she says. Reminding them of those benefits during the conversation is useful, as they may not be top of mind at the time. “It’s looking at the whole picture,” Overman says. “Help them look outside that paycheck as a way of feeling a part of the team, of being well compensated and recognized.”

If a raise isn’t in the cards, consider other ways to leverage your workforce.

Make the most of practice staff

Managing the money tied to patient encounters at each step along the way is critical, but in an era of high deductibles and tightening payer reimbursements, revenue management is an increasingly complex task.

Patients are more commonly required to pay something out of pocket. Insurers require more data. How can practices improve their revenue cycle management (RCM) process in the midst of all this change?

For some, it may take support from vendors, revisions to internal processes, the deployment of additional technology tools, or a combination of all three, according to experts.

Many of the challenges practices encounter throughout the RCM cycle are outside their control. The current shift in patient payment obligations is one such issue.

“We have a lot of people choosing low-premium health plans for economic reasons,” says Timika Lucas, MBA, president and chief executive officer of Lucas RCM Consultants Inc. in Hazel Crest, Ill.

Magnifying the effects of that trend is the move toward high-deductible plans as consumers seek to more closely manage their healthcare expenses and usage. “That’s resulting in insurance companies making patients responsible for a higher percentage of their care costs,” Lucas says. As patients see their out-of-pocket expenditures climb, an increasing number are finding it difficult to pay, or to pay on time.

Recovering payments from patients is a challenge Lucas sees across the private practice spectrum, particularly when the dollar amounts are higher. Working with a multitude of payers - a portion of the industry also undergoing significant changes in the current environment - presents its own difficulties.

“A lot of reimbursement is regional, so it depends on payers in your area and what kind of programs they have and their level of sophistication,” says Drew Borland, chief technology officer at Alpharetta, Ga.-based Philips Wellcentive, a population management and revenue growth platform provider. Navigating through compliance requirements that are still maturing adds to the complexity for practices. “The issues are evolving as we go from an incentive-based world to a value-based penalty world, where if you don’t do things with a certain level of quality, then you can get dinged,” Borland says.

The practice's lack of time, a phenomenon that seems to be getting worse rather than better, is another factor hindering practices’ efforts to recover the highest possible reimbursements. Moreover, physician burnout sometimes keeps providers from focusing on RCM and the components that go into it.

“They don’t always have good knowledge of the revenue cycle, and they don’t have the time to look at it,” says Ginny Shipp, professional services at revenue cycle technology firm Waystar, in Duluth, Ga. She says she doesn’t believe it’s necessary for providers to directly manage the RCM process, but too few have a working familiarity with how the cycle works or what a solid RCM strategy looks like if they do oversee it.

Lucas points to common internal work flow issues as another potential barrier to maximizing revenue. She says staff already have a full plate when it comes to complying with payer requirements.

“[Practices] need to make sure that preapprovals are obtained, or they need to make that call to the insurance company to find out if it’s necessary or not,” she says. Insurers may change policies and requirements for certain procedures, but staying abreast of each update is difficult and time consuming.

“Support staff may not have that ability, or they may have staff multitasking and doing more than one job,” Lucas says. Newer practices just starting out often find themselves in this position most frequently, but if staffing is too lean to make RCM a priority, physicians could leave money on the table.

Practices trying to brighten their financial picture sometimes head in the wrong direction because of incorrect assumptions made on a limited amount of data. “They will look at a canned report out of their practice management system, and it shows them something but it doesn’t get to that granular level of what those numbers really mean,” Shipp says.

It's important that a physician identify very clearly where and why their RCM strategy is lagging before they chart a course forward toward a solution. Without that insight, they may end up addressing only the symptoms of an inefficient process, and Shipp says, “They’re not actually fixing the root cause of the problem.”

Efficient protocols on the front end can help practices improve their revenue picture. Lucas suggests calling to verify patient information a day or two in advance of a visit whenever possible.

“Make sure the patient demographic information is accurate and updated, along with any insurance information,” she says. “That information being incorrect can cause a ripple effect and have reimbursement delays more than anything else.” A number of EHR and practice administration platforms provide tools to help track patient eligibility and assist in capturing the necessary RCM data. Some also offer practices “warning signs which can help their current staff catch things before they go out to clearinghouses to be processed,” Lucas says.

Back-end processes factor heavily into a practice’s success with revenue improvement. Clinical documentation, for example, must be clear and concise if services are to be accurately coded.

It’s also vital that physicians be responsive to inquiries about their documentation. “Coders may need to ask questions about what the provider has documented for that patient visit,” Lucas says. “[The coders are] making sure they’re capturing everything so they can be reimbursed correctly.” An experienced consultant can be a useful resource for examining existing workflows and identifying where internal processes should be improved to secure better reimbursement levels.

Coding protocols are an important area of focus when it comes to RCM improvement efforts. Incorrect and missing codes are frequently the cause of diminished and delayed reimbursements.

“Maybe a person is diabetic and hypertensive but you only coded them diabetic,” Borland says. “Comorbidity pays better than a single chronic condition.” An experienced coding specialist can often spot these potential errors or omissions, whether that means in-house staff working on RCM-related efforts or partnering with a vendor who can provide that service. New technologies focused on coding optimization - often powered by artificial intelligence engines and vast databases of coding patterns and commonalities - can also help a practice be more accurate and thorough. The results are a higher reimbursement rate and fewer missed dollars.

Simply taking a more prominent role in the revenue process may help physicians maximize reimbursements. Shipp encourages physicians to learn about RCM and gain a better understanding of the process.

“They would be significantly more comfortable participating in helping to maximize that revenue cycle,” she says. “They need to know what the revenue cycle looks like and what the steps are. And it starts when the patient is scheduled.” Knowing that the patient experience plays a heavy role in determining where consumers spend their healthcare dollars, physicians - as the care providers and revenue producers - need to be familiar enough with the revenue cycle to engage in reviewing RCM performance and targeting opportunities to improve. More knowledge may also provide a better footing to make process and technology decisions for the practice.

“You don’t have technology just for the sake of technology, but you don’t kick it out the door just because the patients may not like it,” Shipp says. Practices need to commit to an educational process and making the necessary adjustments when it comes to implementing any new software platform.

Clearing the patient payment discussion hurdle

Developing workable protocols for handling the patient side of the payment equation is an important step. Begin by being open with patients on their likely financial obligations.

“With some insurance companies, you can go online and see how much the patient may have to pay out of pocket,” Lucas says. She adds that discussing payment arrangements and agreeing to a timeline is also a useful strategy. “Give them options, such as payment plans that fit their budget.”

How patients pay, whether it’s by phone, through the patient portal, or even via automated billing if the practice has the technology to support it, should be discussed, along with when payments will be made and the amount of each installment. Throughout the process, practices need to be diligent in maintaining open communication with the patient. Their out-of-pocket estimate may need to be adjusted, or the payment terms amended to keep the financial picture on track.

Some practices will need to take a step back and establish a more formal financial policy when it comes to patient payment responsibilities. “Even if they do have a policy, not every practice is transparent about it,” Shipp says. It isn’t that practices intentionally hide their protocols, but many are hesitant to communicate them openly.

“There’s still a huge discomfort around talking about money with patients,” Shipp says. Taking a look internally at the different types of patients, such as those on Medicare or with high-deductible plans, can help put some structure around the payment options that make sense for each type. Accepting a health care financing credit card or similar program is one point to consider, and if the practice has any other kind of support it can offer the patient, the staff needs to be aware of that and have information ready to hand to patients.

Even as physicians work to improve their revenue management processes, inertia and human nature may still stand in the way. For instance, relying on meeting the various benchmarks popular in the industry can sometimes lead to complacency.

“It’s good data, it’s real data,” Shipp says. “But by just meeting those benchmarks, [practices are] not pushing as far as they could go to capture all the revenue they’re owed.”

If a practice has a 9 percent denial rate when the benchmark is 11 percent, for example, that figure should be seen as offering room for improvement rather than being good enough.

“You have to capture every penny,” Shipp says. “The days are gone where you can afford to write off with insurance companies or patients.”

Every penny matters in health care, so be sure physicians and staff have a grasp on how that money flows through the practice.