Laird Harrison

Avoiding seven common communication errors can boost the productivity of the average medical group by 80 percent.

So claimed Skip Weisman of Weisman Success Resources, a Poughkeepsie, NY-based consultancy. Weisman outlined the "Seven Deadliest Communication Sins" for attendees at the 2016Medical Group Management Association (MGMA) annual conference.

Communication leads to three possible outcomes, he said. It can increase trust and build a relationship, slowly erode trust and the relationship, or instantly destroy trust and the relationship. Favoring the first possibility over the other two takes constant effort from practices, he said.

Weisman cited reports by Towers Watson, ComTIA, Cognisco and Siemans which found that the average employee wastes at a good amount of time per day because of poor communication. To this point, Watson outlined seven communication sins that practices commit, killing productivity and ultimately, income:

Seven communication sins every practice should avoid

You can avoid these seven deadly sins by instead making sure your communication is prompt, direct and respectful, Weisman advised.

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A lack of communication can lead to inefficiency in medical practice, says one expert. What are a few communications sins to avoid?

Creating good governance structures and providing leadership training can increase physicians' engagement in medical groups, according to Marc Mertz, vice president of GE Healthcare Camden Group, a healthcare consultancy with offices around the country.

Mertz teamed up with Peter Valenzuela, chief medical officer of the multispecialty Sutter Medical Group of the Redwoods, a multispecialty group of 125 providers in Santa Rosa, Calif., at this year's Medical Group Management Association (MGMA) annual conference, held at the Moscone Center in San Francisco, Calif. Together the two explained how physicians can take more important roles in running medical groups.

More and more physicians are employees rather than owners of their practices, said Mertz, and this is causing them to feel less invested in the practices' success. Mertz cited a 2006 survey by Jackson Healthcare in which 36 percent of internists and 51 percent of surgical specialists were "actively disengaged" from leadership.

"This is just a recipe of disaster," said Mertz. "We'll never be able to respond to the opportunities and the challenges of the market if you have this level not only of non-engagement but active disengagement."

Addressing the problem requires involving physicians in the vision, strategy, operation, and oversight of the practice so they develop a sense of ownership, even if they don’t have legal or financial control, Mertz said.

Where physicians legally own a practice, they may have a role in the governance through a board of directors. But as employees physicians either have no formal place in medical practice governance or may only serve on advisory boards with no real power.

Instead, physicians should take leadership positions near the top of the organization. "You can call it what you want," Mertz said. "It could be a joint operating committee of a physician leadership council. The key is the physicians are at the table with the administrators dealing with high-level issues."

The physician leadership council or committee can then delegate to subcommittees nitty-gritty decisions, such as finance and technology. These subcommittees can offer an opportunity for young physicians to get involved in some issue they feel passionate about, and this experience will help develop their leadership skills, Mertz said.

Physicians should also help make decisions throughout the medical group, Mertz said. He recommended dyad structures in which a physician is paired with an administrator.

But creating a structure for physicians to participate won't help the organization unless physicians have leadership skills, said Valenzuela.

Sutter Medical Group of the Redwoods drew up a list of leadership skills from the book "FYI: For Your Improvement - Competencies Development Guide" by Heather Barnfield and Michael M. Lombardo. The top leadership asked physicians and their administrator partners to choose the leadership skills they wanted to improve.

The administrators and physician leaders identified 10 skills to work on, and chose coursework from the Harvard ManageMentor online curriculum that focused on those skills. For example, one module coached the leaders on how to run better meetings.

It can be challenging to justify the time physicians take away from clinical care and the money spent on such training, Valenzuela said. But the group has seen a 25 percent increase in work relative value units (WRVUs), a 41 percent increase in total patient encounters, and 28 percent increase in internal referrals from 2013 to 2015, suggesting that this work has paid off.

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Medical groups should encourage and develop physician leadership skills, so that all physicians are optimally engaged in running the practice.

How to Engage Physicians in Leadership

Attention to the details of population health management, patient experience, and accounts receivable can a transform a troubled medical group into a high-performing one.

That's the experience of administrators from three medical practices designated as "successful medical groups" by the Medical Group Management Association (MGMA), who were part of a presentation at the organization's 2016 Annual Conference in San Francisco, Calif.

"If I can [solve problems], any of you can do [the same], because trust me, I have my challenges," said Alicia Vaughn, practice manager of Dawson Pediatrics in Dawsonville, Ga. Vaughn's practice struggles with low reimbursement provided by Medicaid, which covers 64 percent of its patients.

When Vaughn started as practice manager, Dawson was being audited by CMS for not complying with EHR requirements and other discrepancies. The person in charge of billing had no experience with billing. Vaughn paid for the billing person to attend coding school. And, she explored the alternatives to fee-for-service reimbursement that CMS was offering, finally settling on the Patient-Centered Medical Home (PCMH) model.

This approach fit into the work she did on improving the practice's EHR system; Vaughn found she could take some of the documentation burden off the practice's providers and also identify patients in need of more care.

The practice began to call patients in more frequently for wellness visits, identifying those whose chronic diseases were not under good control. For example, if a patient called to request an albuterol rescue inhaler this might suggest his asthma was not well managed, so the practice would schedule an appointment with the patient.

The practice also increased routine screening for conditions such as lead poisoning and tuberculosis. "We are projecting in one year a little over $200,000 increased revenue," Vaughn concluded.

For Jennifer Souders, practice administrator of Hilltop Family Physicians in Parker, Colo., the key to success has been improving the patient experience.

When she came to the practice 17 years ago, a patient who called in with a sore throat would be scheduled for an appointment later in the week. "That's not OK," she said. "If you're sick, you need to be seen that day." Hilltop now reserves half of every day for same-day appointments.

Next, Souders analyzed every step of the patient visit, from the front desk to checkout, making sure that the staff was on top of details such as collecting the right payer information.

The practice has streamlined its patient satisfaction surveys to just six questions, and is getting high marks on all of them. It keeps track of which payer is associated with the patient filling out the survey. "We can go to a payer with this, and maybe get our payments increased," Souders said.

Michael Shadley, practice administrator of Illinois Gastroenterology Institute, in Peoria, Ill., focused on making sure his practice gets properly reimbursed for each patient visit. The process starts with carefully tracking details about each patient's insurance coverage and details of each visit. Illinois Gastroenterology Institute collects copayments before the patient sees the doctor. "They pay a lot better on the front side than on the back side," Shadley said.

The practice will accept payment installments as small as $50, but only if patients agree to have the money automatically deducted from their bank accounts by a collection agency. "The people who aren't paying you are taking up spots from people who are willing," he said.

Administrators got together at the Medical Group Management Association's Annual Conference to share best practices for running an outstanding practice.

MGMA's 'Successful Medical Groups'

Reorienting a primary care practice toward value-based compensation requires buy-in from everyone who works there, according to Meryl Moss, chief operating officer at Rhode Island-based Coastal Medical, an accountable care organization (ACO) of 24 primary care practices.

Speaking at this year's Medical Group Management Association (MGMA) Annual Conference in San Francisco, Calif., Moss described how Coastal Medical achieved a 100% ACO quality score from CMS for 2015 by meeting all of the agency’s required benchmarks while also reaping more than $24 million in aggregate shared savings over three years.

The key was convincing everyone to take a leap of faith in the new payment model, she said.

In 2009, Coastal Medical organized itself as a patient-centered medical home. But the medical group still found that something was missing.  

“We discovered that it wasn’t enough,” said Moss. “We wanted desperately to get away from fee-for-service. Our docs were on a treadmill.”

So in 2012, Coastal Medical began participation in CMS’ shared savings program as an ACO and embraced value-based payments. The transition created tension within the organization as leaders realized as each year was coming to an end that it had not yet met its benchmarks. In a frantic effort to reach these goals, Moss recalls a lot of “screaming and yelling.”

Physicians resisted the administration’s efforts at reorganization.  So administrators summoned staff and providers to a meeting. They challenged everyone to envision the ideal primary care practice and to suggest ways of achieving that vision.

 “We put this all up on the board and they came up with fabulous ideas,” said Moss.

Administrators expected providers to suggest centralizing operations, for example with a call center. But some came to the meeting specifically to oppose that idea. Instead they suggested centralizing clinical programs including pre-visit planning, prior authorization, prescription refills, diabetes management, transitions of care, quality monitoring, and laboratory diagnostics.

So the administration set up a pilot program, asking each practice to designate its practice manager and one physician to participate. It stipulated that if the pilot was successful, the new approach would be rolled out to the entire practice. And it required that office managers report to corporate supervisors instead of to physicians.

The staff complained that there were no clear routes of promotion, so the administration allowed medical assistants to apply for the higher-status jobs being created in the new centralized services.

After working out the kinks in this pilot program, the administration put the new management structure in place throughout the group.

• About 75% of patients are in shared savings arrangements;
• The average doctor is now seeing about 60 patients, down from 104 in 1999;
• The percentage of patients with very high HbA1c levels decreased by two thirds; and
• Skilled nursing facility and emergency room visits have dropped sharply.

“It’s really hard, but we really believe it’s the right thing to do,” Moss said.

One medical practice made the transition to embrace value-based care, but not without achieving some obstacles first. Here’s what it learned.

Making Value-Based Payments Work in Primary Care

Acquisitions will go more smoothly if medical practices plan ahead for the logistical and emotional challenges.

"Don't get so caught up in the 'wedding' plans you forget that the next morning, you all will wake up in bed together," said Linda Zinkovich, Chief Operating Officer for Primary Care and Medical Specialty Practices at Orlando Health in Orlando, Fla.

At this year's Medical Group Management Association (MGMA) Annual Conference in San Francisco, Calif., Zinkovich offered 10 tips for avoiding problems during acquisitions. She based much of her insight on her own experience from the acquisition of her former employer, the 85-physician group, Physician Associates by Orlando Health four years ago.

Medical practices should negotiate details such as how billing, recruitment and compensation will be handled before they sign on the dotted line.

Not everyone on either side is going to like this.

Often the objections will come from an unexpected direction, Zinkovich explained. Perhaps a vendor will be angry because of getting cut out of the new purchasing agreements. Sometimes patients will complain.

At Orlando Health, the opposition to the acquisition of Physician Associates came from hospital nurses who thought money for the acquisition had prevented them from getting raises.  "For these nurses, we were the worst thing that ever happened to their health system," she said.

If the mission and values of the two organizations are not aligned, everyone can anticipate a long period of conflict, Zinkovich said.

4. Be careful what you ask for. You might get it.

It's important to think through the long-term consequences of arrangements that look good in the short term, Zinkovich said. For example, physicians at one practice acquired by Orlando Health negotiated higher salaries for two years, but may have difficulty adjusting when that period ends and they have to take big pay cuts.

5. Due diligence on both sides means more than just looking at finances.

Practices being acquired should make sure there are no lawsuits and no CMS actions pending against the entity acquiring them. Also find out that they are comfortable with everyone in that entity's top management.

6. Really evaluate what you want long term and focus on getting those during negotiations.

While some physicians may want higher salaries, others may want more autonomy. For the physicians in Zinkovich's practice, the most important point was to maintain control.

7. Start "living together" as soon as possible. 

Before the acquisition becomes official, start work on reconciling practice management systems, EHRs and other systems, Zinkovich advised.

8. Remember that compromise takes both sides giving something up.

Think carefully about what which battles you pick and remember sometimes the other side is right and you're wrong, Zinkovich recommended.

9. It is very difficult for those who have been owners and in charge to suddenly become employees.

Physicians in particular can be stubborn about changing the way they practice, said Zinkovich. She urged administrators to talk it through with everyone involved in advance.

10. Charts (patients) are not necessarily an asset that has monetary value.

In assessing the value of a practice, patients are not seen as assets because they are not necessarily loyal.  "What is of value is the profit you make," Zinkovich said.

Here are 10 ways to ensure that an acquisition between a medical practice and its purchasing organization will go smoothly.

10 Things to Know Before Being Acquired

Management of a medical practice often depends on the partnership of an administrator and a physician who share decision making and problem solving.

“I’ve taken the words ‘command and control’ out of my vocabulary for many, many years,” said Bruce Bagley, MD, who once led a family practice and is now senior advisor to the American Medical Association (AMA) for professional satisfaction and practice sustainability.  “It’s all about influence and education.”

Bagley teamed up with Allison Winkler, MPH, a senior practice development specialist at the AMA to present strategies for improving teamwork at this year’s Medical Group Management Association (MGMA) Annual Conference in San Francisco, California on Monday (Oct. 31).

The balance of power is shifting in medical practices because physicians no longer control all the information, Bagley said. The advent of smartphones and other handheld computers has allowed administrators quick and easy access to clinical data.

But many practices have not caught up to the new reality, he said. “We’re still operating on the ‘hero model’ where the doctor is the source of all information.” In this model, the physician’s authorization is required for most orders, and the staff works to optimize the physician’s workflow and throughput.

This approach stems from the assumption that the physicians’ clinical expertise translates to expertise in leadership and management, said Bagley. Administrators are seen as employees, setting up a dynamic that can discourage them from taking initiative and innovating.

Instead, successful practices will move to the “team model,” in which the physician supplies clinical expertise, everyone makes decisions appropriate for their level of work, 

and the entire team participates in optimizing outcomes for patients, Bagley said.

“In family medicine, probably 30% of what the family physician does every day can and probably should be done by someone else,” he said.

He proposed a simple test: If the physicians in your practice use the phrase “my patients” and the staff uses the phrase “Dr. So-and-so’s patients,” then the practice is not operating as a team. One hallmark of a team model is that everyone refers to “our patients.”

Bagley and Winkler recommended a “physician administrator dyad model” in which both leaders work together to create an integrated model of care, sharing responsibilities for all strategic objectives. The keys are trust, communication, integrity, and positive attitude, they said.

Winkler introduced the AMA’s “Steps Forward” 

 with instructional materials in video and text on creating such strong teams within a practice through such measures as team meeting “huddles,” and effective team meetings.

In the oncology practice where Winkler worked, the huddles brought together representatives of every part of the organization, she said.

“It was an opportunity for us to meet and really have detailed discussions of issues that were going on in the practice.”

Successful medical practices will employ a team model in which physicians supply clinical expertise and everyone partners for better patient outcomes.