Patrick Watterson, PA-C

“The reports of my death have been greatly exaggerated.”  Much like Mark Twain, the death of private practice has been greatly exaggerated.

Rumors of its demise began in the early 1990s, when a wave of hospital practice purchasing took place.  In this first wave, hospitals only looked at the referral revenue and missed the bigger picture of having to actually run and grow these practices.  As the misstep was realized, these business deals quickly unwound, often at a great loss to both parties.

More recently, declining insurance reimbursement and increasing government regulations are pushing many physicians and their practices toward hospital ownership and employment. While this has some positive aspects, many of the negatives will come out later. And, similar to what occurred after the first wave in the early 1990s, I believe that private practice will again make a comeback.

As a result, I recommend that physicians think long and hard before selling to hospitals. In the meantime, here are a few steps they can take to maintain their independence:




It’s not just what you collect in the office.  Think about the X-rays, labs, and referrals you send out.  Without the physician, these sources of revenue do not exist.  According to recent surveys, the average physician brings 1.45 million dollars a year to its affiliated hospital.  These numbers can go up to 3 million to 4 million for some specialties, such as orthopedics and interventional cardiology. 


Your goal is to keep as much of the revenue in your pockets. not the hospitals'.   Add X-ray, add lab testing, and other ancillary services.  The initial investment cost will be paid shortly in additional revenue. Also, keeping these services in house makes for happier patients who now don’t have to travel all over the place for these services.


The average patient does not know the quality of the actual medical care he receives. They do know the quality of the service they receive.   We all need to give quality care but it is the outstanding service that will make your practice thrive. 


Nine to five should only exist as an old movie.  Be there for your patients.


Call at least a few patients yourself with routine lab results.  This surprise phone call will result in them telling 10 of their friends about your call, and therefore, boost your referrals. 


Join with other like-minded independent physicians.  The economy of scale benefits all business. Partnerships can be a challenge but the benefits far outweigh the negatives.  Group practices further build on the economy of scale benefits while often relieving physicians of the day-to-day task of running a business.  Do you lose your independence in a group?  Some, but not as much as you would by answering to the VP of your local hospital.

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I recommend that physicians think long and hard before selling to hospitals. In the meantime, here are a few steps they can take to maintain their independence. 

Six Ways Independent Physicians Can Stay Independent

Whether you are an Apple fan or not ("Droid Heads"), you have to admire Apple's design. You can hand an iPhone to a 3 year old and the child will quickly understand swipe, pinch, etc. Somehow, because of the way the phone is designed, we intuitively know how to do what we need to do. Wouldn't it be nice if that design approach was brought to EHRs?

Imagine an EHR that is put together to work, not just to meet meaningful use (or as I like to say, meaningless) regulations.

If I'm seeing a diabetic patient for a follow up, why do I have to go looking for the last HgbA1c or lipids? An intuitive EHR would already have those results pulled up and in front of me before I walk in to see the patient. It would also remind me t

hat the patient is due for his annual eye exam or microalbumin. If a refill was running out, a pop up window would alert me. If the patient recently turned 50, I would receive a colonoscopy alert.

Sure some EHR programs do these functions, but not one EHR that does all of them well. Most only have these options when you are in the patient's chart, or they require someone to run a report from the database. Intuitive programming would automate these processes.

When the government decided to invests millions in the HITECH Act, its intent was to spur EHR adoption but, as often happens, we ended up with a tool to meet government regulations and not to make life better for our patients.

While many EHR companies have made millions from this, where are the real innovators? Where is the Steve Jobs of EHRs?

Don't get me wrong, I am a fan of the potential of EHRs, but the current programs lack the forward-thinking abilities that we need to see in the future. We are stuck using old BlackBerrys when we really should be using Siri or even a Droid.

Imagine an EHR that is put together to work, not just to meet meaningful use (or as I like to say, meaningless) regulations.  

What if EHRs Were Designed like iPhones?

Working in a practice that offers multiple on-site ancillary services, I often get the pleasure of talking with insurance company doctors in order to get “approval” for medically needed testing.

Join us Sept. 19 & 20 in Philadelphia at 

, our new conference for physicians and office administrators to help improve your medical practice and your bottom line.

Here are a few of my tips based on my experiences:


	The first strategy insurance companies employ is to make it inconvenient for you to gain approval. They know the hours and time demands we all have, and they probably figure that many of us just will not have the time to call. 

To make the most of your time spent dealing with prior authorization requests, ask your staff to take on the upfront part of the call. You should only get on the call once a doctor is on the line and ready for you to discuss the need for the ordered service.  Let the doctor wait for you, not the other way around.


	Most of the doctors you are talking to will approve what you want as long as you have a good medical reason.  Don’t start off with a bad attitude.  It will only make things harder.


	In some cases, you may do everything right, and the doctor still says they will not pay for the test.  Remember, the doctor is denying “payment” not “treatment.”   

The insurance company's primary goal is to keep the premiums people have paid them.   Turn the tables on them and suggest the most expensive way you can think of to get a test done. Mention that you can just send the patient to the ER for further evaluation and to get the necessary CT, ultrasound, etc.  Or, mention that you will just send the patient to a specialist who will order the same test.

Instantly, the doctor on the other end of the line will see dollar signs adding up in his head and he will be more likely to approve your request.

If all else fails, I always tell the doctor I will let the patient know about the denial and I will document in the chart.  While they claim they have no liability, this sometimes will make them change their minds. 

I have about a 95 percent success rate with these approaches. When I do receive denials, I often send patients on to specialists for consultation or for re-evaluation for other testing or treatment options.  In the end my goal is to get the needed care for our patients. 
	 

I have a 95 percent success rate when attempting to gain “approval” for medically needed testing. Here are some of my success strategies.

Obtaining Prior Authorization: 3 Success Strategies

Over the years, I have found that a common problem in healthcare teams is not the content of the communication shared with patients and staff but how it is presented.  No one is too educated or too highly paid to practice common courtesy.

Some of the most powerful words in the English language are please, thank you, and you’re welcome. Unfortunately in our busy lives and high stress jobs, we often forget these powerful words and how they can help us. 




"Please" sounds nicer than "do this."   It automatically puts staff and patients in a mental state of wanting to help.



, get me the hospital notes for the patient in room 205.  

, get off your butt and help.  See, even that last example, sounded nicer with the please before it.



.
I didn’t have to say thank you because I said please.  Right? Wrong. Please should always be followed by a thank you.  If people complete what you asked them, cement that bond by saying, "thank you." 

, for helping Mrs. Smith. 

People may not remember the details of what you asked them to do but they will always remember whether you said please and thank you.

Never forget to thank patients and staff when they say nice things about you.  One of the greatest honors in healthcare is the trust that our patients put in our hands.  




Did part of your brain want to say, "You’re welcome" when you read, "thank you"? If this is not a reflex in your brain yet, make it!  You’re welcome tells the person thanking you that you appreciate his kindness and were happy to help. 



, if this was helpful to you and your practice.

Over the years, I have found that a common problem in healthcare teams is not the content of the communication shared with patients and staff but how it is presented.  

Physicians: Don't Forget Common Courtesy in Your Medical Practice

By now, you've likely heard and read about accountable care organizations (ACOs). Though the concept of ACOs has certainly gained momentum over the past year, and more and more healthcare systems are forming ACO arrangements, I don't believe they are the best way to improve care quality and reduce care costs.

"are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

The biggest push now is for accountable care organization contracting by Medicare and insurance companies.  The carrot being offered to participants is a percentage of the “shared savings.” 

While at first look this appears to be a win-win, a simple business example shows why this is not a sustainable approach.

Let’s pretend we have a widget-making factory with 100 employees.  The factory is contracted to produce 100 widgets a month for “X” amount of dollars.  If the factory can do it for less, it keeps the extra profit.  It can design the manufacturing line, it can coordinate supplies, and it can make sure it doesn't duplicate processes. 

The factory does not have the means to provide higher salaries to employees, but it can can suggest they work as hard as possible.  

Ultimately, the factory finds that 34.9 percent of its employees do not assemble the widget correctly, 18.1 percent don’t package it correctly, and 7.1 percent don’t even show up to work. 

As you would expect, this factory would not be very efficient and would not be in business long.

If those percentages look familiar, they should. National data shows these trends for the United States:  obesity is 34.9 percent of the population, smoking is 18.1 percent, and alcoholism is 7.1 percent. 

It is these difficult to change behaviors that lead to these health problems. 

This is not even considering the impact of medication non-compliance, financial challenges, other drug abuse, etc. 

Until patients have an incentive cost wise to adjust these behaviors, we are very limited in changing the outcomes in healthcare.  Healthcare is not a widget factory; it is a business at the end of the day.  ACOs are not the cure to what ails our healthcare system.

Though more and more accountable care organizations are cropping up across the country, I don't believe they will be effective. Here's why. 

The Problem with ACOs: No Incentive for Patients

Recently we suffered a multi-part network crash at our practice of four locations, 20 providers, and 180-plus staff that prevented access to our EHR and practice management system.  The first few hours were tolerable as these things happen from time to time but then the magnitude of the problem became larger as more and more vendors had to be involved.

Want to learn more about how to lead your practice through challenging times? Join us Sept. 19 & 20 in Philadelphia at 

, a new conference for physicians and office administrators to help improve your medical practice and your bottom line.


I won’t bore you with the technical details but let’s just say the problem involved the server, network, firewall, router, etc.  The total down time was four and a half days - four times longer than our longest ever outage.   A lifetime for a medical practice.  

It is times like this that physicians and other practice leaders have to step up - whether they like it or not.



Here are some of the lessons I learned while helping my practice deal with the disaster. I hope they come in handy should you ever face similar circumstances:

1. Stay focused and calm

. As the old ER saying goes, “The first pulse you check in an emergency is your own.”  Don’t get emotionally bogged down by worrying about what could happen, focus on what you can do.  You are useless if you join the panic.  Stay focused on the objectives not the emotional reaction of your staff.  Acknowledge it but keep moving!  Believe or not, some people don’t handle stress very well (wink).



2. Communicate, communicate, and communicate!  

Nothing instills fear like not knowing what is happening.  Information voids will always be filled with rumors and conspiracy theories.  Even if it is a simple update of, “We're still working on it,” go ahead and let people know.  At my practice, we kept staff calm and in the loop through e-mail, texts, phone calls, and overhead announcements.  I would have used smoke signals or Morse code if I had to.



 Look for alternative information to continue safely seeing your patients.  No med list, call the pharmacy;  no lab results, call the lab vendor (or in our case, use another computer system for the in-house lab).  Most of what we do with patients is still the familiarity we build over multiple visits, not just the numbers.



 They are on the front lines with you getting hit with anger and frustration from staff and physicians.  Meet with them and give them time away from the heat when needed.  Use them to be your eyes and ears to see where your more stressed staff and physicians are, and then move resources to that area.



During trying times, pull out all the stops. We bought pizza, doughnuts, candy, and coffee for staff and physicians.  Anything you spend is well worth it!

After many vendors and many long hours, we were able to bring the network back up.  We didn't lose any data, and all of our paper notes were eventually entered into the EHR and processed to our practice management system.   We lost less than 15 percent of our monthly revenue due to this event, and the good news is I think I only aged 10 years in four days.

Recently we suffered a multi-part network crash at our medical practice. Here are some of the lessons I learned while helping my practice deal with the disaster. 