Learning to Negotiate

May 1, 2007

I am a pediatrician working in a clinic affiliated with a large academic faculty group. In our office, there is insufficient room for our nurses and other staff, and at times our parking lot overflows. Our administration has been aware of the problem for some time and has promised an expansion, but this is now on hold. I can see about 30 patients a day. We are now fully utilizing an EMR, which has slowed things down a bit for us. The current pace is barely tolerable. Yet each day my schedule fills up by morning, and we are turning patients away. This is unpleasant for everyone and is not good medical care. Our administration has failed to respond to requests to help us work out solutions for these problems. Adding provider time wouldn’t be an option due to space constraints. As a result of all of this, I asked to close my practice. I was denied. I was told that I can’t close because HMO patients who’ve selected me as their primary-care provider have the right to see me even if I have not yet seen them and they have no appointment on the books. Is this legally correct? What are my responsibilities regarding new HMO patients? What are my options if I truly feel that taking on new patients compromises my ability to provide quality medical care?

Question: I am a pediatrician working in a clinic affiliated with a large academic faculty group.

In our office, there is insufficient room for our nurses and other staff, and at times our parking lot overflows. Our administration has been aware of the problem for some time and has promised an expansion, but this is now on hold.

I can see about 30 patients a day. We are now fully utilizing an EMR, which has slowed things down a bit for us. The current pace is barely tolerable. Yet each day my schedule fills up by morning, and we are turning patients away. This is unpleasant for everyone and is not good medical care. Our administration has failed to respond to requests to help us work out solutions for these problems. Adding provider time wouldn’t be an option due to space constraints.

As a result of all of this, I asked to close my practice. I was denied. I was told that I can’t close because HMO patients who’ve selected me as their primary-care provider have the right to see me even if I have not yet seen them and they have no appointment on the books. Is this legally correct? What are my responsibilities regarding new HMO patients? What are my options if I truly feel that taking on new patients compromises my ability to provide quality medical care?

Answer: Try to view everything you’ve described as a negotiation.

To start, you need to review your practice’s HMO contract. The administration will no doubt deny this request, explaining that you don’t need - or have no right - to review the documents. Perhaps you can simply see a photocopy of the language pertaining to closing the practice. Or can you see the language that explains why you can’t close? There’s no need to get nasty. Much of what practices think is “illegal” is merely an opinion about something someone heard once. That said, it might be absolutely true. You just need to know for sure what you are dealing with.

Ideally, of course, you will decide to keep your practice open. But it’s certainly not acceptable to be forced into delivering what you consider inadequate patient care.

It is not in the interests of the administration, which doesn’t want you to leave, for you to have insufficient space or access.

In any case, your options basically are: find a new job, find a way to work it out, or suck it up. The middle option is the best, unless you really think you can find a different practice that will be better.

To achieve the middle option, try to identify the administration’s concerns and then attempt to propose and negotiate solutions that work for everyone.

For example, if there is a nearby practice that isn’t as busy as yours, you could route patients there or have one of its providers work in your practice on a part-time basis. I understand that your office is already overcrowded, but if someone else - a physician needing more hours, or a PA - comes in from 5 p.m. to 7 p.m. and Saturdays (when you and some others are not working), there is no additional demand on space. And if you can prove that another provider working such hours would add profitability and access, isn’t the administration likely to go for it?

You also need to press hard for maximum efficiency. In terms of space, can physician offices be transformed into exam rooms? You shouldn’t need to use them for dictation since you have an EMR and can do real-time documentation. Set aside one small room that all physicians share for patient counseling. What happened to the space where all those paper records were stacking up? If you still have them, store them securely off site and use that space for staff or exam rooms.

As you grow more accustomed to the EMR, you’ll become more efficient there, too. Spend as much time as you can entering data into the system ahead of time so that documentation happens faster at the patient visit.

In short, think it through yourself. Propose solutions to the administrators. If they don’t go for them, a possible next step is to call a meeting of all physicians to share ideas and seek proposals for the leaders of the organization. Your practice surely isn’t the only frustrated one. That should get their attention.