Laurie Hyland Robertson

A couple of years ago, my own physician sent me a hand-scrawled note along with some lab results that had turned out normal: “Hope you’re feeling better!” No provider before or since has made such a gesture - I’d call it alternative practice, in fact - and it’s one that really stuck with me.

But the majority of allopathic physicians would draw a Sharpie-thick line between my doctor’s action and “alternative care.” Why is this so? And does it really make sense for today’s healthcare needs? Consider that nearly three-quarters of Americans have sought “alternative” medical treatment at some point in their lives. Odds are, most of those folks are also the patients of allopathic physicians - they’re your patients. Clearly, they’re seeking something they’re not getting in more mainstream practices.

I see some providers automatically characterize the distinction between these care philosophies as “evidence-based medicine” versus “complementary and alternative medicine.” Is a clear division even helpful in treating today’s hyper-consumers (some of whom may, regardless of how misguided the notion, feel that they themselves have nearly as much expertise as their physicians)?

Maybe it’s time to consider a new way of looking at these boundaries.

A few more questions to ponder: Given the standard painkiller-plus-muscle-relaxant prescription for back pain, is simple, supervised exercise an alternative treatment for a bad back? It’s a cheap (and relatively effective) one, to be sure. But because it’s alternative, in the sense of “not done very often by traditional physicians,” does that make it suspect?

Physician rants against alternative medicine - as it’s more typically defined - are pretty common on the message boards and online communities I have regularly trawled for 

. Much of the vitriol falls into the category of opinion, and frankly, not a lot of the comments could be considered “evidence-based” under even the loosest definition of that term. As plenty of physician writers have noted, what constitutes evidence for one group - say, a young, male university student who is Caucasian taking part in a trial - isn’t necessarily relevant to members of any other group, but the “evidence” is often applied as if it is. And a lack of such “evidence” is used frequently to condemn with broad strokes.

Granted, the pool of available patient dollars seems to dry up a little more each year. But wouldn’t expanding the list of provider types to whom you refer benefit your patients? Are we really talking about a zero-sum game?

Maybe it’s time to think about eliminating the bitter undertone of competition from discussions of patients’ health choices.

Sure, the alternative medicine world has its quacks and charlatans. (As does allopathic medicine - consider the reproductive specialists who must’ve been involved in the infamous octuplet case.) So naturally, a heaping helping of due diligence is in order. As is undertaking your own education on available treatment options. Your patients will see other providers either way, so wouldn’t you rather be in that loop, ensuring that the care they receive is legitimate? 

It only makes sense to help patients get the most out of the time and money they’re inclined to spend this way anyhow. A nonjudgmental attitude from you will also make them more likely to tell you when they’re trying a new diet tea that could interact with the heart medication you so carefully prescribed.

Maybe it’s time to stop resisting and start considering how alternative medicine can play a part alongside what you do.

She speaks nationally on practice management issues, and is also co-owner and manager of Whole Chiropractic Healthcare, in Odenton, Md. She can be reached via 

Articles

Reconsidering Alternative Medicine


At the busy group we’ll call Rural Internal Medicine,* there’s a lot going well. Satisfaction and loyalty run high among patients, staff, and physicians alike. Revenues and cash flow are steady. Their EMR is up and running, with nary a stray scrap of paper in sight at this three-physician Maryland-based practice. Really, everything’s hunky-dory, with just one exception: Payers who continually change their already-inscrutable rules. 

“The administrative part is just unbelievable,” says practice administrator Jean Ellis.* “I’m not nasty by nature [but] you really feel as if nothing will get done if you don’t adopt a split personality.” The practice gets it done, but Ellis increasingly wonders whether the time devoted to certain relationships is worthwhile, and she and her billers bemoan the fact that they’re often forced to play hardball - not to mention a constant game of “Mother May I” - with payers. 

Although Ellis’ staff seems to be doing just about everything that can be done to make payer interactions as painless as possible, a check-up is sure to uncover additional opportunities to improve. To effectively address these issues, Rural Internal Medicine - and other practices that may not be so adept at playing the payer game - will ultimately need to break them into specific problem areas, looking perhaps at slow payers, eligibility and authorization questions, poor reimbursement, and simply pinning down shape-shifting policies. Here is an overview to get things rolling. 


Ellis’ billers track insurer hassle factors by running regular queries from the practice management system, graphically analyzing, for example, response to level 4 and 5 submissions by payer group to detect denial patterns. As a result, the practice now strictly requires that patients sign advanced beneficiary notices, and they’ve made a decision to always “bill what they’re doing,” regardless of the expected payer response. A small sign on the front desk alerts patients that a number of payers are on the practice’s watch list; patients with these plans are advised to seek guidance from their HR departments or insurance brokers to determine whether they might be able to switch to an alternative company. 

As insurance company “customer service” becomes an ever more egregious misnomer, patients increasingly look to the practice for information about their coverage. This forces the staff into developing considerable expertise on a myriad of payers’ plans and policies. There’s a tipping point to all this learning, where holding onto certain payers may no longer make sense. Payers that represent a relatively small proportion of patients or those that set up roadblocks to providing good care should go on the watch list, or even be cut. Limit participation only to those plans offering the most juice for the squeeze, so to speak. 

For denied claims, focus efforts on the most damaging types. According to revenue cycle management firm athenahealth, coverage-related problems result in particularly long cycle times. Expect to wait up to 40 percent longer to get paid for those claims than for claims denied for other reasons. Clearly, the before-visit, new-patient process merits extra attention. Perform whatever verification activities you can in advance. This is your chance to find out what copay or deductible the patient might be required to pay - and to communicate that information, as well as reiterate your billing policies in no uncertain terms before she arrives at your reception desk, grinning sheepishly and saying, “I’m so sorry - I must’ve left my checkbook at home today!” 

Information on patient copays, deductibles, and coinsurance amounts is increasingly available from payers, so make use of it. Many consultants say that online is the most reliable way to obtain eligibility data, and Rural Internal Medicine’s experiences bear this out. Particularly problematic payers, however, may necessitate a multimedia approach - for some, the automated phone system is the most up to date, whereas others’ reps are the prime source for reliable information. Add this to the list of payer quirks to know and track. Unless a payer has full-on real-time adjudication - which precious few currently do - online systems may prove best for general checks of eligibility rather than determining coverage for specific tests or procedures. 

Athena and others, such as the consulting firm The Verden Group (through which you can sign up for payer policy change alerts), also maintain databases of evolving payer rules, informed by the claims they process for their clients, so that practices using their services don’t have to expend the energy to keep up. Even the smallest practices are starting to outsource billing and collections in response to the type of difficulties Rural Internal Medicine is facing. As payer rules become more complex, automating billing functions through a revenue cycle management company is becoming more attractive to avoid the tedium - and, let’s face it, the increasing impossibility - of keeping track manually. 

Another tactic to make things easier in the long term is maintaining a master file of verification forms for each carrier and group. Take time to update the forms annually (or more often, if coverage changes) and cross-reference them with your denial reports, but you’ll have a single go-to spot for basics, such as copay amounts, along with the payer’s contact information. Organizing the billing and collections teams by payer also makes administration a little easier, as each biller only has to remember the rules of a handful of payers rather than all of them. 

Ellis should also selectively approach payers about their rules. For example, if a payer requires preauthorizations but then approves them 95 percent of the time, present that data. Perhaps preauths aren’t really necessary for “routine” care? 

More burden-reduction strategies that lie outside the practice itself include a scanning lockbox, which would have the bank receiving and processing EOBs, and remote capture for checks - both simple means of increasing efficiency in the face of rising payer demands on Rural Internal Medicine’s time. 

In addition to carefully prioritizing which payer quirks most urgently require staff attention, Rural Internal Medicine should also give top billing to the larger issue of streamlining its approach to payers’ administrative requirements. Perhaps while payer concerns remain initiative Number One, the practice would continue to verify every patient’s eligibility, even though that may not be the best ongoing use of staff effort. 

It’s OK to shift your primary management focus, and to create task forces to address particular problem areas. You’ll avoid staff fatigue and the problem of being blinded to an issue, which can happen in the presence of a constant low-level background drone from a host of smaller problems. True, there’s no silver bullet to fix the problem of burdensome payer rules, but resolving the above little things is at least a start toward a larger solution.

This article originally appeared in the March 2009 issue of Physicians Practice.

A busy internal medical practice learns to push back at payers’ administrative requirements.

The Great Practice Makeover: Undue Burden


Bill Sinclaire, MD,* has a tough decision to make. The payer that covers 40 percent of his patients reimburses at levels that verge on scandalously low - below Medicare, below Medicaid, and below every other payer in his area. As a result, he and the other psychiatrists in the Southern practice where he’s medical director are seriously considering dropping this payer. Still they’re justifiably worried about the hit revenues will take, and about what will happen to their patients who can’t afford increased out-of-pocket expenses. 

Sinclaire brought in a consultant to work with this payer’s reps to try to improve rates, but the consultant hit a brick wall. “I think she was sort of led on for a couple of months,” he says. “They talked with her as if they were open to negotiation. She got together claims data to submit to them, and after talking to them over about a period of two months, [the payer] came back and said that they weren’t willing to negotiate, and in fact the rates were set across the state.” 

Even more maddening, Sinclaire knows of several other specialists who have had success in negotiations with this particular payer. But that’s actually good news: It means Sinclaire shouldn’t give up. 


Aside from knowing that this payer can be negotiated with, Sinclaire has a few more tools at his disposal for dismantling this intractable payer’s brick wall. 

He definitely needs to push back on the assertion of a set rate across the state. With the exception of certain aid programs, it’s unlikely that a truly mandated rate exists. A national rep from this particular payer tells Physicians Practice that the company absolutely does not have a ban on negotiating with psychiatrists, so, frustrating though it may be, at least one more salvo is in order. 

Sinclaire needs to conduct a detailed review of the terms of each contract - not just the ones he feels are especially onerous. Although he has a fairly good handle on his various payers’ allowables, a closer look wouldn’t hurt. Too many solo docs unwittingly end up employing an overly simple heuristic as a substitute for thoroughly analyzing the true patterns occurring in their practices. Too many also assume they’re actually getting paid the contracted rate, and plenty more aren’t attempting to objectively classify each payer’s “hassle factor.” 

Try a simple ranking method that accounts for the volume of procedures, automatically assigning greater weight to the reimbursements attached to the services you provide most frequently: Over a period of six months to a year, calculate average total dollars received per visit. Take the total amount collected for each contract or government program, and divide it by the number of patient visits over the same period. The resulting values will help you more accurately compare your payers. 

In addition to objective fee schedule criteria, consider more subjective measures such as physician and staff time to collect on claims, and the time and effort involved in resolving administrative issues such as credentialing or trying to recover disputed claims. Look, too, at average number of appeals required and time spent on preauthorizations for each payer’s patients. 

Sinclaire might also consider contracting with additional plans in the area, or at least approaching them, so he’ll have more information with which to “prove” the going market rate to the poor payer. Colorado-based consultant Marcia Brauchler often helps clients negotiate with managed care companies, and she recommends compiling a list of your state’s insurers, along with how many covered lives each one represents, to target your efforts to the players that matter in your market. (The state insurance commissioner should be able to provide this info.) 

Creating your own carve-outs also can be an especially effective strategy for specialists, too: “Mr. Insurer, how about you pay me 120 percent of Medicare’s rate for codes X and Y” - codes that constitute a sizable proportion of your business, of course - “and I’ll make you a deal! I’ll accept just 85 percent of Medicare for every other code I bill!” 

Before you take the step of dropping a poor payer, tell them about your plans. Pointedly. Take the matter as high up the food chain as you possibly can, and enter the discussion armed with data. For Sinclaire, that would include his perpetual two-month waitlist for initial consultations and a limited number of colleagues to whom he can refer the overflow. Patient satisfaction data and any compelling outcomes stats would come in handy as well. 

Also ask patients or their caregivers to contact the insurer - and their employers’ benefits offices - on your behalf. It’s like politicians getting pressure from their constituents, and payers do listen. 

Finally, says Brauchler, find out if your state has on the books a statute or regulation requiring that managed care companies maintain sufficient providers to ensure “network adequacy.” Indeed, Sinclaire’s state has such a rule, which may mean that the payer must reimburse providers in a given specialty - the non-contracted folks, anyway - their billed charges (not just the payer’s allowable) if the ratio of patients to providers is too low. 

Some quick searching turned up more potential ammunition for Sinclaire’s negotiations: The county where he practices is a federally described Health Professional Shortage Area, a designation made by Health Resources and Services Administration of the Department of Health and Human Services. The bottom line: Don’t give in too easily, as help is available. 


Still, if the brick walls won’t budge, Sinclaire may eventually be forced to drop this payer. 

A loss of the magnitude the practice would likely suffer will be tough to weather. But exactly how big would it be? And how long could Sinclaire survive on that reduced revenue? Here again, base your projections on actual data from your practice. 

“What we’ve thought about doing is staging a withdrawal,” says Sinclaire. “We’d have one person drop off [the payer’s panel] and build their practice back up, and then have another drop off … .” This would be a time-consuming undertaking given the approximately 20 providers in Sinclaire’s practice, potentially stretching on for years, but it may be the best way to avoid crippling the practice’s cash flow and ensuring that the physicians feel comfortable with their patients’ continuity of care. 

They’ll have to be careful, of course, not to simply have all of Dr. A’s patients transfer to Dr. B when A drops the payer. And at the very least, assuming your contracts allow this, don’t accept any new patients under the plans you’ve determined aren’t worth dealing with. (Another reason you’ll have to be intimately familiar with each of your contracts.) Continue the patient education campaign, too, making sure staff have clear answers to pass along when that payer’s patients come calling. 

Plan ahead, ideally giving patients at least six months’ notice that you’ll no longer be accepting their insurance. Although there’s no need to delve into specifics, tell them why. Just keep it simple and non-accusatory (no whining!), and offer a list of the plans you will continue to accept (or otherwise explain how they’ll be able to pay you if you’re going completely cash-only). Try to post patient notices about changes in your practice’s contracting during early fall, as that coincides with most employers’ open enrollment periods - loyal patients may be able to switch plans to one you’re still accepting. 

Scan contracts for an “evergreen clause,” which means that your contract will automatically renew unless you give advance notification that you want out. The clause may stipulate that you submit notification a certain number of months in advance, or you may only be able to terminate during a certain period each year. You may also be obliged to continue accepting that payer’s patients, both new and established, for up to 12 months after terminating a contract with them. 

Terminating a payer contract may not be as easy as you’d think, but in the end that step may not be necessary anyway. 

This article originally appeared in the February 2009 issue of Physicians Practice.

An in-demand psychiatrist needs help leveraging his popularity for a more appropriate fee schedule.

The Great Practice Makeover: He Wants More Money. But He’s Worth It.


Kristin Murphy*, administrator of an anesthesia group, has a common complaint: “I’m having trouble recruiting intelligent people who can work independently for part-time work,” she says. “And when I finally get them trained, they leave as soon as a full-time position is offered to them. How do you find quality individuals who just want part-time work?” 

A familiar conundrum, but one that’s potentially devastating to a practice’s productivity, particularly when the staff in question handle your billing. Murphy has been filling the gaps with college students, whom she praises as fast learners, as well as with previous employees willing to work a few hours here and there. But the college kids are usually onto the next thing after a semester or two, and former employees are not reliable long-term, which is not too surprising. They had their reasons, after all, for leaving in the first place. 

All of this leaves Murphy spending precious time and energy training an endless string of new hires - and the practice’s cash flow on shaky ground - as everyone focuses only on meeting the next deadline. “It’s starting to burn out myself and the other gal who has been here a long time, having to constantly train people,” says Murphy. “It puts you behind on your own work.” 

She says the practice can’t afford to hire a full-time biller, and indeed, it doesn’t currently have enough work for another one anyway. But making the search for admin help even more challenging is the fact that even part-time candidates increasingly want benefits, too, such as health insurance coverage - essentially impossible to offer for this practice. “Since we are a very small company, our benefit costs are astronomical,” says Murphy. “We have dropped group healthcare coverage and put employees on individual plans.” 

Murphy feels she’s done her due diligence in terms of staffing analysis - she’s convinced that what she needs is part-time help - and maintains that her “current employees are working their patooties off!” Still, she wonders whether she’s overlooking anything that would help her retain quality part-timers, which is certainly possible. How to find out? 

When you’re faced with a situation as seemingly intractable as Murphy’s, start by questioning your underlying assumptions. In this case, that might mean determining whether the workload really doesn’t merit an additional FTE, and whether the folks you already have are working efficiently and at full capacity. Conversely, in light of the current complexities inherent in the reimbursement environment, it’s also worth analyzing whether a college student, no matter how bright, could actually be costing more than he saves. A top-notch billing pro could potentially bring more dollars in the door, which would cover that person’s salary and then some. 

Bringing in an additional FTE really might be justified if this new billing person proactively corrects issues on the front end. For Murphy that could even mean working with the facilities where her docs have privileges to improve, over time, the information coming into the practice. After all, says Murphy, “The part-timers are not there to fix their [own] mistakes,” and they don’t necessarily have a sufficient personal investment in the practice to consider their work a career. If she ends up correcting the same errors over and over - a snowballing time-waster if ever there was one - even the quickest short-termer becomes a liability. 

Possibly, the next step could be to entertain ways to take on 

 work to better justify an additional FTE (and then more realistically be able to offer the benefits in the first place). The physicians at this southwestern U.S. practice tell Murphy they’ve never enjoyed such profitability as they now have with her leading the administration. “We have a fabulous collection rate because we appeal so many denials,” she says. And, she says, the docs are thrilled with the staff’s ability to keep current with changing carrier rules. Idea: Perhaps it’s time to bring that expertise to a wider audience and seek economies of scale by taking on billing or other services for outside physicians. 

Or go polar opposite and outsource your billing. Consider a revenue cycle management vendor that would provide regular reporting. If you don’t like the idea of forking over a flat fee, consider an RCM company that charges using a percentage scale - if they don’t perform, you don’t pay. 

Offloading non-revenue-producing administrative work to a professional employer organization is another possibility. PEOs undertake a host of HR functions, usually for larger practices, but the value for Murphy could come primarily in the form of access to benefit programs. Expect to pay a fee or a proportion equaling about 4 percent of payroll for these services. Although it would mean giving up at least some control of staffing, that cost could be worth it to a practice like Murphy’s, which can’t find affordable health coverage for its employees and has trouble locating worthy job candidates. 

Providing an attractive work environment certainly helps draw candidates. This practice offers perks such as flexible hours and dress for those in clerical positions. And, she points out, plenty of the previous part-timers 

 end up wanting to come back at some point, even if only for short periods or, say, around holiday spending season. 

Perhaps Murphy could establish a more formal coverage network comprising these alums, a sort of extended job-sharing arrangement that would provide them a bit of increased financial stability. In exchange for being more regularly available, these folks might receive a slightly higher hourly rate, reflective of Murphy’s reduced training burden. 

Murphy plans to expand her applicant pool to more specifically include older folks as well. “We’ve advertised at the schools, Mother’s day out, churches, daycares as well,” she says. But the practice is located in an affluent area where women in their child-raising/parent-caretaking years - the group you might typically look to for such roles - tend to pursue either charity work or leisure activities to fill their spare time. “My applicants come from farther away, and as such really want full-time in order to make it worth the trip.” 

The specialty of anesthesiology presents some unique challenges. Obviously, one is the inability to capitalize on an often-fruitful recruiting avenue - the practice’s own patients. 

On the other hand, relocating the office to a neighborhood with a larger applicant pool (and lower overhead?) could be an option, as patient-facing activities all take place in off-site facilities anyway. 

Certainly, traditional advertising isn’t out of the question to find well-qualified folks, although word of mouth may ultimately prove most productive. For starters, ask local IM practices to keep their eyes peeled. Murphy might also look to retail and other service businesses in her immediate vicinity. And think creatively - even store greeters might have a lead for you. Approach one who’s on the ball and impresses you, and say you’re looking for someone with a personality like hers. Perhaps you can offer the attraction of a better work environment … Upon hearing this suggestion, Murphy’s understandably a little skeptical: “Oh, don’t tell me my next biller is going to come from Wal-Mart!” But you never know, do you? 

where we’re talking about how you find reliable part-time employees. 

This article originally appeared in the January 2009 issue of Physicians Practice. 


It’s a common problem: How do you find competent administrative staff willing to work part time? We help one practice solve this conundrum.

The Great Practice Makeover: Skilled Part-Timers Needed


Brian Dionne’s* overhead is threatening to eat him alive. 

OK, not really. But at an excruciating 86 percent - compared with a 63 percent average - that’s how it feels to this earnest, energetic pediatric practice administrator. 

As in plenty of other primary-care oriented practices, Dionne nervously watches the prices of supplies and services creep up while reimbursements stagnate or even sink. Meanwhile, payments that do come into the practice require an ever-increasing level of effort to process. 

But that’s not all. This practice is also dealing with a new physician-owner transitioning in. And the pricey office space is situated in a sleek facility that also houses a variety of sports and fitness amenities. In his geographic area, says the administrator, “Other practices pay $15 a square foot; we’re at around $30 a square foot.” And that figure doesn’t include taxes, or maintenance and cleaning. 

And if that weren’t enough, here’s one more financial drain: all the paper, and consequent time-consuming cross-checks - required to maintain a smoothly functioning practice. Years ago, “When [the practice] was started, everything had a purpose; it was very well organized,” says Dionne. “Everything is double-checked - by color, number, letter code - so misplacing a chart is very hard.” 

Given mounting staffing and supply costs, however, such protocols - quite advanced in the not-so-distant past - are becoming more and more difficult and expensive to maintain. Naturally, Dionne hopes to minimize that outlay while maintaining the failsafes. But how? 

Dionne’s opinion is that much will be solved by implementing an EMR system as soon as possible, preferably within the next few months: “If we just eliminated the transcription and the physical charts and copying and faxing, that alone would pay for an EMR.” 


But hang on: The equally important flip-side of this overhead coin is the revenue coming in. It’s too low, in fact, and that’s skewing the overhead percentage even higher. “Our patient load is going down a little bit,” Dionne admits. This has rippling repercussions: According to his accountant, prices on essentials such as vaccines have tripled over the past year, so patient volume declines are “hurting the practice more, and it’s harder to make ends meet.” 

It won’t be long, Dionne fears, before the practice is no longer viable at all. An EMR ain’t gonna fix that - at least not in the short-term. Before incurring such a major expense, the practice needs to figure out why patient visits are down. 

For starters, this practice has been around long enough to have year-over-year numbers on which to accurately base trending. Because of monthly variations, which can be dramatic in peds, it’s tough to get a valid comparison if you’re looking only at this past April compared to this past March. Is the practice experiencing a natural seasonal slowdown or the effects of provider transition (the practice’s original owner stopped practicing a couple of years ago), or does the problem run deeper? 

Fact is, most practices lose money on an EMR implementation - often quite a bit - for the first year or so after going live. Some actually add staff and increase office hours initially just to accommodate the learning curve and account for conversion issues such as misplaced charts and scanning of old files. 

Plus, many of the savings Dionne has so carefully totted up won’t be realized instantaneously. For instance, it’s going to take time for decreased spending on paper folders, stickers, and specialized forms to make a significant difference in the practice’s bottom line. 

Basically, it costs money to switch from paper to EMR, so make sure your practice can 

 to kick itself off the EMR cliff. I’d recommend that Dionne make the EMR transition a long-term goal, and instead immediately focus every available resource on ramping up his revenues. The practice really can’t afford to divert attention from the need to increase patient visits and making sure the most is being made of each one. At 3,500 active charts, the patient panel is simply too small right now to support three providers (two MDs and one NP) in a primary-care specialty. 

I’m all too accustomed to having my many calls to physicians answered with a curt, “Practice XYZ-can-you-hold?” delivered all in one breath. But such brusque treatment went to the next level during a call to this practice: I was put on hold straight off, without so much as a hello. 

This is not to imply that all subsequent service is lacking in the practice - because there were many subsequent thumbs-up moments as well - but before having your head turned by electronic bells and whistles, look back to the basics. Flawless customer service is the primary way for practices to improve patient retention, not to mention increase referrals. 

Amanda Clymer, an experienced medical practice biller who’s been in the business for nearly 30 years, joined the staff a few months ago. “I’ve never worked with a nicer bunch of people,” she says with enthusiasm. The practice is also fortunate to have those three dedicated providers - an advantage to highlight in marketing and on the practice’s Web site, where the staff bio section currently sits empty. Simply stating for employees a renewed focus on patient service may be all that’s needed to ensure that customers feel well-loved and keep coming back. 


The practice’s location is another barrier to bringing in patients. Unlike a more suburban or even urban location, the fitness facility isn’t a place that parents will automatically consider when they’re picking a pediatrician for little Johnnie. Dionne suspects that at least some patients are transferring to physicians closer to their homes or offices, or even taking their children to their own family physician because of the one-stop-shopping convenience factor. 

I’m not suggesting that the practice pull up stakes and move, particularly as that pricey triple-net lease was recently renewed for a three-year term. But the practice should make darn sure to reap every possible benefit from its location - and from that lease. 

Dionne is taking steps down this road. “I was just talking to [the center’s management] to see if we could have a closer relationship with them.” For example, he says, “Maybe when we give a Lamaze class we give [the patients] a tour of the facility. And [the center] would extend the courtesy and give a tour of the medical facilities available in the complex” when new clients come in. 

Not a bad idea to pursue, although the practice will want to beware of any activities that could divert time from the practice’s existing patients. Is there some perk they could offer parents through a one-time negotiation with the fitness center? An upgrade on membership in the health club, or maybe discounted tennis lessons for the kids? 

Clymer says that Dionne “has some excellent ideas about marketing, which I’m encouraged about.” 

“I’m going to brand the practice - theme it,” says Dionne. He describes a fun sports-ball motif carried throughout the décor and marketing materials. Makes sense given the office location, and the practice might take this a step further by reaching out to the summer-camp and Little League sets to offer sports physicals, injury rehab, and training guidance. 

Dionne has also started staggering staff shifts to cover busy times, and is “considering changing operating hours to accommodate more patients later or earlier.” 

Do it whole-hog if you’re going to do it, though. The current nine-to-five weekday and Saturday-morning-only “urgent care” hours won’t be sufficient to get people thinking of the practice as the go-to spot for after-hours treatment, and they’ll have to give folks a concrete reason - improved care continuity, a more personal approach, 

 - to entice them to bypass the perceived convenience of the urgent care center or, worse, the retail clinic. 

Other ideas Dionne would like to pursue, including in-house prescription dispensing and even an ear-piercing service, should probably go on the back burner for now. A deep breath and a critical look will tell him there’s either not enough potential for immediate profit or too much effort and expenditure required to do these things right. 

Every number in this practice is affected by the computer system that we use,” explains Dionne. In addition to being on the EMR hunt, he’s less than thrilled with the current practice management software. “We need to reduce the amount of time that it takes for us to receive our collections,” he says, worried about the complexity of the billing system and again raising the specter of cash flow. 

Clymer takes a slightly more sanguine view. She admits that the practice management system isn’t the most user-friendly, but she has a lot of experience with it and plans some streamlining in the weeks and months to come. Clymer also stresses that she’s not yet fully up to speed in her new position, especially after an illness forced a two-week absence early on. 

For most practices, staff costs consume the largest portion of the operating budget, and she notes that this one recently lost three experienced employees. The learning curve involved in replacing them contributes to the outsized overhead, too. 

“It’s those things - having to learn new systems because the person who knew it or set it up is gone - that have thrown us, but I’m getting a good handle on it,” she says. “For so long we were just treading water, trying to keep up with the day-to-day claims submissions.” She’s happy to report that following up on collection calls has now made it back onto her daily to-do list, and Dionne is even happier that they were able to close out this month’s accounts a full two weeks earlier than the previous month. 

When dealing with new systems and staff, some amount of trial and error is unavoidable, but this practice is on the right track. Dionne’s challenge - and that of the physicians - is figuring out what’s truly a problem, and what just needs time to work itself out. “I did panic when I first got here, because so many things were undone,” says Clymer with a laugh. “But it’s getting better now.” 

The accountant and/or a financial advisor may be able to help with tax-planning strategies to increase the amount of cash on hand and ease those cash flow worries. The practice will also want to plan expected outlays each week, paying bills strategically within their 30-day windows, and ensure that an adequate line of credit is in place for emergencies. 

Before further straining the practice’s finances with a major new software purchase, even one that stands to improve cash flow in the future, spend some time focusing on the top opportunities for bringing patient visits and revenue to a more comfortable level. 

The bottom line: If your patient-procedure mix isn’t profitable when you’re on paper, breaking into the black will be even harder when you go digital. 

This article originally appeared in the October 2008 issue of Physicians Practice. 

A pediatric group gets help resolving its digital decision.

The Great Practice Makeover: EMR - Help or Hindrance?

Have you been pondering striking out on your own, making the leap from employed associate to practice owner? Or are you just starting out in practice, and wondering if it’s worth going even deeper into debt to start your own venture rather than getting “a job”? 

Whatever your situation, Physicians Practice is here to help with our comprehensive six-part guide to starting a medical practice. In addition to the pre-opening day planning advice you may have seen in other such guides, we’ll delve deeper into the key milestones you’ll need to meet for success long after you cut the ribbon. 

It’s a favorite daydream of many new practice owners: becoming “self-sustaining” so that they no longer have to spend time soliciting business and can really get down to patient care without distraction. And while no successful practice ever stops attending to patient relations, plenty of practices do eventually reach a point at which they don’t need to focus resources on formal marketing. In the beginning, you need to make connections with potential patients and sources of patients, marketing yourself and letting people know what you have to offer. 

“People like my office, they like the experience, they refer their friends and family, and I don’t have to do any marketing,” says West Virginia dermatologist Beth R. Santmyire-Rosenberger. “We haven’t done much advertising for the past year, and we’re booked. Most of our referrals are word of mouth.” 

But in specialties that were previously the domain of the well-connected super-doc with a stable of referral-funneling colleagues, patients are now shopping around a lot more, even with referrals in hand. “Things have changed,” says Marilou Terpenning, MD. “Today, many of my patients ‘interview’ me before deciding to receive treatment with us.” 

Because of this propensity for doctor-shopping, many practices will need to begin building in time for extended consultations and simply consider them part of the cost of doing business, as in Terpenning’s Santa Monica hematology/oncology practice. 

In general, now is the time to spend a little of your personal capital on precious extra minutes with patients. Make sure they have a stellar experience from the very first scheduling phone call to the final bill and beyond (patient satisfaction surveys, anyone?). 

As Santmyire-Rosenberger notes, “An opinion of me and my office is formed before people even meet me.” How quickly the phone is answered, how pleasant the receptionist is, whether the plants in the waiting room are wilting - such seemingly trivial things make a big impression on patients. 

Experienced practice owners’ top marketing suggestion is a classic technique that pays off even in a hyperlinked digital world: Give in-person presentations in your community. 

“There’s no substitute for becoming known,” says Terpenning. “It’s a low-cost way of getting your name out there.” Libraries, larger employers, and schools are all likely candidates for hosting educational physician presentations. Find out who makes such decisions in your target organization - often HR directors in large companies, the principal or business manager in schools - and approach them with a proposition to offer a free seminar on, say, diabetes management or some other relevant health topic. 

While you’re out there, ask attendees what they think they’re lacking in their own healthcare providers, and what they can’t seem to find elsewhere. Focus on making those things part of your practice; most likely, you’ll hear less about particular services than about the type of physician and practice people want. You can also offer yourself up to local newspapers and TV stations as a subject-matter expert; large-format display ads and infomercials are usually available, too, but these types of outreach can be too expensive for new practices to comfortably afford. 

Consistently highlight your unique attributes in any messaging that leaves the office, whether it’s via paid or unpaid channels. For example, if you can offer patients more time with you than most physicians, because it’s part of your long-term strategy, then make sure people know it. “Seeing fewer people, for longer [visits], reinforces the relationship-forming and sustainability of the psychological component of practice,” says internist and pediatrician Chrissie Ott, who has adopted that strategy in her Portland, Ore., practice. 

Or maybe you offer a full range of genetic counseling services, like Terpenning. Whatever it is, find ways to let people know. Shout from the rooftops if you have to. You’ll need to make sure your messages are understandable to the lay public, of course, so if, for example, you’re the only board-certified specialist in the region, you’ll want to think about what “board-certified” signifies to a potential patient. 


Remember that all of this will take time to pay off. Think in terms of long-haul relationships with community contacts and with the audiences who attend your presentations - give tactics time to bear fruit before dumping them in favor of the next exciting idea. 

Do, however, track results by asking every patient how they found you. That pricey phone book ad may not be worth it if it’s only netted you a few patients after a year. A well-considered sponsorship, on the other hand, might be just the thing. Terpenning’s practice, for instance, highlights its work in breast and ovarian cancer every year by sponsoring a team in the Revlon Run-Walk for Women to raise money for research. 

When most people think of marketing, traditional media is usually what comes to mind. And it’s true that folks in many areas of the U.S. are today far more accepting of radio and billboard ads from physicians than in 1982, when the AMA lifted its ban on physician advertising. 

In fact, members of the new generation of tech-savvy “healthcare consumers” expect to be able to easily find and compare information on medical providers and facilities. Witness the ads from individual practices increasingly popping up as sponsored listings on Internet search pages. When carefully deployed, such electronic advertising campaigns - which can be conducted regionally, nationally, or internationally, depending on your needs - are a relatively low-cost way of dramatically increasing a practice’s visibility. 

And it’s not just wired youngsters and urban professionals who are eager to connect digitally. The vast majority of people with Internet access want the ability to e-mail their physicians: One survey a few years ago pinned it at 90 percent; others say the figure is in the high 70s and going up every year. According to AARP, 82 percent of baby boomers use the Internet for everything from e-mail to managing their finances and playing online games. 

New technology tools are increasingly at the intersection of marketing activities and a sound patient relations strategy. There’s value, to be sure, in having your practice perceived as a leading-edge tech adopter, but most compelling for patients may be improvements in access to information. 

“Technology enables possibilities for community health, for example, letting cancer patients share information with their siblings - and their siblings’ physicians - across the country so that they can obtain targeted genetic counseling,” explains Terpenning. Patients place great value on information-sharing, she says, and appreciate her practice for providing high-quality educational resources. Serving as a trusted repository for such tools makes patient loyalty that much easier to win. 

Other physicians also cite technical prowess as important for patient relationship-building, with many saying that enhanced Web services, improved links between office systems, and even e-visit capabilities are near-term goals in their practices. 

Ott, for one, has accomplished the dual aims of being tech-smart and increasing her patients’ responsibility for their care: She hired a Web designer to create an easy-to-use but highly functional online scheduling system. Because Ott knew what she needed from such a system, she was able to avoid pricey software packages and subscription fees by going custom. A certain amount of DIY effort is required, she says, “but it’s no big deal - I can adjust open hours and holidays on my own through an editing function.” 

Her patients, too, are expected to put in a little DIY time by selecting their own appointment types (and, therefore, visit lengths) from a menu of options. Ott’s off-the-shelf calendar program syncs up with her cell phone, allowing constant access to a schedule that she can quickly update upon receiving an automatically generated new-appointment notice from the system. 

Ott says 90 percent of her patients use online scheduling, with good results (not to mention low overhead). “So far I am not having trouble with patients overbooking themselves too much,” she says. “There may come a time when I feel more pressed for minutes, but so far it is working well.” 

If you go the technology-as-patient-relations route, those solutions had better deliver what they promise. Given increasingly difficult customer service interactions in other industries, at least some consumers are primed to be frustrated at having to use automated systems rather than getting live help. 

Physicians who start with manageable technologies will be able to gradually increase the services they offer, incorporating new features into their practices as revenue warrants. And don’t forget that each new capability represents a chance for patient outreach - when you start offering a hassle-free scheduling option or secure e-mail communications, your community will want to know about it. 

Terpenning notes that it’s far better to begin modestly than to make a grand announcement about, say, your new interactive Web site, complete with bells and whistles. This goes for other patient relations strategies as well. Think of the eager, energetic young doctor who sends out a splashy practice newsletter, promising monthly publication, but never again finds the time to work on the project. 

Patients and colleagues are left to wonder about his follow-through in other areas, and future announcements are more likely to meet with skepticism. It’s OK to have a basic Web site and add to it over time - that’s eminently preferable to having a bunch of pages perpetually “under construction” and “coming soon!” 

Be aware, too, of the ways in which you’ll be judged in the brave new interconnected world. Santmyire-Rosenberger recommends paying heed to physician rating sites such as DrScore.com or RateMDs.com. You can’t always control what ends up on these sites, but as of this writing, about 120 patients on DrScore had given Santmyire-Rosenberger near-perfect scores in overall exam, timeliness, treatment, and staff. 


What constitutes a good “exam” or “treatment” to a patient may not align with your clinical judgment, but it’s helpful to know what evaluation criteria patients are applying: How long they sat on the table in that drafty gown, whether three people asked them the same list of questions, whether the nurse returned their phone call right away. 

Often, a patient relations plan is simply a question of how best to show patients you care. Customer-service manuals oriented toward general business - Santmyire-Rosenberger likes “Raving Fans” by Ken Blanchard - can provide food for thought. Even a business school classic like “How to Win Friends and Influence People,” written by Dale Carnegie in 1936, offers plenty of pointers for those whose business necessarily includes winning over patients, payers, and colleagues. 

Terpenning cautions new practice owners not to forget about those colleagues: Relationship-building with other physicians must be on any practice’s list of patient relations tactics. “Make referring physicians’ lives easier,” she says. “Show them why they’d want to send patients to you, with timely, high-quality reports and easy access to you. Let them know that their patients are getting top-notch care with you, which reflects well on them.” 

Ultimately, says Santmyire-Rosenberger, “Patients want to feel that you’re interested in their best interest. The more they sense that, the more they trust you.” With a wide base of patient trust, your practice will be able to generate the community traction needed for growth and sustainability.

Laurie Hyland Robertson, BA, is a senior editor with Physicians Practice. She has been in the medical publishing field for more than 10 years, working editorially on both clinical and business-oriented healthcare topics. She can be reached at 

This article originally appeared in the September 2008 issue of Physicians Practice.

You didn’t think you could just hang a shingle and wait for the patients to come, did you? Most new practices have to do a little bit of horn-tooting to build their patient base. We’ll show you how.